BMI Healthcare Limited BMI The Runnymede Hospital Quality Report

Guildford Road, Ottershaw, Chertsey, Surrey, KT16 0RQ. Tel: 01932 877800 Website: www.bmihealthcare.co.uk/hospitals/ Date of inspection visit: 1-3 August 2016 bmi-the-runnymede-hospital Date of publication: 25/01/2017

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Ratings

Overall rating for this hospital Good –––

Medical care Good –––

Surgery Good –––

Outpatients and diagnostic imaging Good –––

1 BMI The Runnymede Hospital Quality Report 25/01/2017 Summary of findings

Letter from the Chief Inspector of Hospitals

We carried out a comprehensive inspection of BMI The Runnymede Hospital on 1-3 August 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of medical care, surgery, and outpatients and diagnostic imaging as these represented the activity undertaken by the provider, BMI Healthcare, at this location. We rated medical care, surgery and outpatients and diagnostic imaging as good. Are services safe at this hospital? • We saw evidence of comprehensive and detailed investigations into incidents and complaints with learning appropriately shared throughout the hospital to improve standards of care and avoid recurrence. Staff understood the duty of candour and we saw evidence of this in practice. • Staff recognised and responded to changing levels of risk for the patient in line with current guidance and best practice. • There were clearly defined and embedded systems to keep patients safe, with staff demonstrating knowledge of safeguarding and an understanding of referral processes. The Director of Clinical Services was the safeguarding lead for adults and children. • There were effective handovers between shifts with information about patients being shared appropriately to ensure continuity of care. Nursing handovers took place three times per day and there was a formal handover between the RMOs who undertook regular ward rounds. • There was a service level agreement with the local NHS hospital which allowed for the transfer of patients who needed additional care. Are services effective at this hospital? • Staff worked to national guidance and followed best practice standards to deliver consistently good quality care to patients, which the hospital monitored to ensure consistency of practice. • The role of the medical advisory committee was clear, with comprehensive paperwork circulated in advance so that members could be fully prepared. We saw minutes which demonstrated robust discussions of policy, shared learning and appropriate challenges • Mandatory training compliance was high across the hospital, with staff able to access additional training for personal development with the support of their line manager. • Although there was no dedicated pain team, staff had received specialist training and were able to discuss anticipated pain levels with patients in advance of their surgery. Patients told us their pain had been well managed. • There was a thorough system for managing the review and granting of practising privileges which ensured there was appropriate clinical and managerial oversight of this. • We reviewed patient records and noted that informed consent was clearly documented, with details of risks and benefits being discussed with patients in a manner which could be easily understood. Are services caring at this hospital? • Patients and their relatives described the care they received at the hospital in very positive terms, with both clinical and non-clinical staff understanding the need for privacy and dignity and taking steps to ensure this. • Patients knew the name of the nurse who was looking after them, and we saw how staff made the effort to include relatives in the care of patients and explained to them what was happening. • The hospital made arrangements to allow parents to stay with their child overnight, and we observed staff being particularly gentle and reassuring with children undergoing procedures. Are services responsive at this hospital?

2 BMI The Runnymede Hospital Quality Report 25/01/2017 Summary of findings

• Appointments were offered promptly to patients with flexibility to suit their preferences as far as possible. Patients told us they were seen on time. • Although the hospital saw very few patients with dementia, all staff had been trained in dementia awareness and were sensitive to the needs of patients living with dementia. • There was a clear process for managing urgent admissions which allowed for better planning and a more effective use of staff time. • The complaints process was well publicised and patients who chose to complain were treated compassionately throughout the process. Senior managers would invite the patient in to the hospital for a meeting, and we saw evidence that managers had visited a patient in their home when the patient did not wish to return to the hospital. • Provision was made to meet the individual needs of patients, including a hearing loop at reception for patients with a hearing disability, a list of languages that different staff members spoke, an interpreting service and careful planning of theatre lists to reduce anxiety for patients with a learning disability. Are services well led at this hospital? • Staff were aware of the overall BMI strategy as well as the local mission statement and understood how it applied to their role and work in the hospital. • The senior management team was highly regarded by staff who told us they found them visible, approachable and supportive. • The registered manager was on annual leave at the time of the inspection but this did not impact upon the smooth and effective running of the hospital. The overall leadership and culture was not dependant on a single individual but continued to be demonstrated by the management team in the director’s absence. • The management team had taken steps to address the difficulties around recruitment and retention of staff by researching salaries across their independent competitors and NHS trusts and ensuring there was pay parity, and by providing training and development opportunities to retain experienced staff. • There was an effective system of governance with departmental meetings and a clinical governance committee with oversight by a well-managed and well attended medical advisory committee. • There was a culture of transparency and honesty amongst staff, who told us that managers actively encouraged them to report incidents. Staff told us they felt valued and respected by their leaders. • There were plans to develop medical services with the provision of four dedicated medical beds. Our key findings were as follows: • There were effective systems to keep patients safe and to allow staff to learn and improve from incidents. • The hospital was visibly clean and we saw evidence that policies were implemented and monitored to prevent the spread of infection. Where audits had shown the need for improvement (for example, clinical staff being bare below the elbows), we saw measures had been put in place to improve performance. • The process for obtaining consent from patients was clear and ensured that staff followed national guidelines and met legal requirements. • Appointments were arranged so that patients could access care when they needed it. • Care was delivered in line with national guidelines and BMI corporate policy. • Staffing levels were adequate, with some vacancies which were managed through the use of bank or agency staff to ensure that there was no impact on patient care. There were robust arrangements to ensure that staff had the required training and skills to do their jobs. • The leadership had the confidence and respect of their staff, who felt supported and motivated by them to provide the best possible care for patients. • There was appropriate management of quality and governance through departmental meetings and committees with regular reports to the medical advisory group for comment, debate and decision. Managers were able to identify risks and challenges within the hospital and were able to escalate and take action as required.

3 BMI The Runnymede Hospital Quality Report 25/01/2017 Summary of findings

We saw several areas of outstanding practice including: • The working of the medical advisory committee, with engagement from members, strong leadership from the chair and an effective working relationship between the chair and both the executive director and director of clinical services. However, there were also areas where the provider needs to make improvements. Importantly, the provider should: • Ensure that the flooring in all clinical areas is fit for purpose. • Ensure clinical staff who assess children are trained in safeguarding children level three. • Ensure that the governance policy is up-to-date. • Consider improving the environment for children in the outpatients department so that it is child-friendly. • Consider providing written information to service users for whom English is not their first language Professor Sir Mike Richards Chief Inspector of Hospitals

4 BMI The Runnymede Hospital Quality Report 25/01/2017 Summar y of findings

Summary of findings

Our judgements about each of the main services

Service Rating Why have we given this rating? Medical care Good ––– Overall, we rated medical care as good. This was because: • Staff demonstrated a clear understanding of incident reporting and there was an effective process which ensured that thorough investigations were undertaken with learning shared throughout the hospital. Staff could describe the duty of candour and we saw evidence of how this had been applied in practice. • Staff were supported in doing both their mandatory training and undertaking additional training for development. Staff spoke highly of the support they received from managers to do this. • All medical staff who treated children were trained to safeguarding level three and the hospital had good links with the local safeguarding teams. • Despite some difficulties in recruiting which had led to a higher level of bank and agency nurse use, patients told us that the care they received was good, with staff taking the time to explain and reassure. • The Medical Advisory Committee met regularly and provided input and challenge where appropriate. • Although there were challenges around the physical environment in endoscopy which meant it could not achieve JAG accreditation, these issues had been raised on the risk register and there were measures in place to mitigate potential risk.

Surgery Good ––– Overall, we rated surgical services as good. This was because: • The hospital had effective systems to assess and respond to patient risk and we saw examples during our inspection. • Staff planned and delivered patient care in line with current evidence-based guidance, standards, best practice and legislation. We saw that the hospital monitored this to ensure consistency of practice. • The hospital participated in relevant local and national audits and contributed to national data to

5 BMI The Runnymede Hospital Quality Report 25/01/2017 Summar y of findings

Summary of findings

monitor their performance such as the National Joint Registry (NJR). Staff we spoke to understood and fulfilled their responsibilities to raise concerns and report incidents and we saw examples of this. • We saw the hospital fully investigated incidents and shared learning from them to help prevent recurrences. • Patient consent was recorded in line with relevant guidance and legislation. • We saw staff treated patients with dignity, respect and kindness during all interactions. Patients told us they felt safe, supported and cared for by staff. • There was a governance structure that promoted the delivery of high quality person-centred care. • Leaders modelled and encouraged cooperative, supportive relationships among staff. The majority of staff told us they felt respected, valued and supported. • Services generally ran on time. Waiting times, delays and cancellations were minimal and the service managed these appropriately. We saw when a delay occurred there was an immediate explanation and apology. However: • There was a low percentage of staff that had undergone an appraisal in 2016, and in addition only 11% of theatre staff had an appraisal in 2015. • We saw that some of the clinical areas had carpets. • Fire doors within the theatre suite did not have intumescent strips around the edges of doors or doorframes. • In theatres we saw three bowl stands had rusty wheels. • We could not find evidence of an electrical safety check on three patient trolleys. • Electrical cables in theatres were not secured. • In theatres there was a door on one of the preparatory rooms with a faulty closure mechanism which was potentially unsafe.

Outpatients Good ––– Overall, we rated the outpatients department and and diagnostic imaging as good. This was because: diagnostic • The outpatients and diagnostic imaging departments imaging provided a broad range of services for both privately

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Summary of findings

funded and NHS funded patients. The patients we spoke with were complimentary about the care, treatment, and service they had received in both departments. • Staff were competent and worked to national guidelines, and ensured patients received the best care and treatment. • The culture within both departments was patient focused, open and honest. The staff we spoke with felt valued and worked well together. Staff followed policies and procedures to manage risks and made sure they protected patients from the risk of harm. • There were short waiting times for appointments. Private patients were seen within one week, and NHS patients were usually seen within four weeks of referral. Patients described that they could get appointments with their chosen consultant and were seen on time. • Patients we spoke with told us they were treated with dignity and respect. All patient feedback during the inspection was positive. They described the service as ‘first class’, ‘very good’ and ‘professional’. • Both departments were visibly clean.

7 BMI The Runnymede Hospital Quality Report 25/01/2017 BMI The Runnymede Hospital Detailed findings

Services we looked at Medical care; Surgery; Outpatients & diagnostic imaging;

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Contents

Detailed findings from this inspection Page Background to BMI The Runnymede Hospital 9 Our inspection team 9 How we carried out this inspection 10 Facts and data about BMI The Runnymede Hospital 10 Our ratings for this hospital 11

Background to BMI The Runnymede Hospital

BMI The Runnymede Hospital is an independent hospital The hospital currently has 52 registered beds split equally which is part of BMI Healthcare Limited. It is located in across Burwood and Wentworth Wards. Ward rooms offer Chertsey, Surrey, in the grounds of a large NHS hospital privacy and comfort with en-suite facilities, satellite TV, and is linked to that hospital by corridor. The hospital telephone and Wi-Fi internet. The majority are single but opened in 1992 providing 30 beds and has since seen there are four double rooms. Two of the three operating extensions to both the ward and outpatient areas. theatres have laminar flow. In house, the hospital provides x-ray, mammography, ultrasound and BMI The Runnymede Hospital provides services for both physiotherapy services with a number of other clinical private and NHS patients. Services are provided by UK services such as CT, MRI, pharmacy, pathology/ registered health care professionals and support teams histopathology and high dependency beds provided by across a range of specialties including orthopaedics, third parties, which did not form part of this inspection. general surgery, gynaecology, urology, ENT, cosmetic surgery, cardiology, physiotherapy and endoscopy. Runnymede outpatient services include eight consulting Inpatient and day case services are offered for children rooms, treatment room, pre-assessment, diagnostic aged three years and above and there are non-invasive imaging, physiotherapy, phlebotomy and cardiology. outpatient services for children of all ages. The registered manager was Leon Newth who had been The majority of patients attending the hospital (79%) in post for just over two years. The provider’s nominated were adults aged 18-74, with 8% of patients aged 17 or individual for this service was Elizabeth Sharp and the younger and 12% aged over 75. Controlled Drugs Accountable Officer was also Leon Newth.

Our inspection team

Our inspection team was led by: • A consultant surgeon • A radiographer Inspection Lead: Elizabeth Kershaw, Care Quality • Four nurses, including a paediatric nurse, a modern Commission Inspection Manager matron, a theatre manager and a Director of Nursing. The team included CQC inspectors and a variety of specialists:

9 BMI The Runnymede Hospital Quality Report 25/01/2017 Detailed findings

How we carried out this inspection

We reviewed a wide range of documents and data we had officer, administrative and support staff and consultants requested from the provider. This included policies, amounting to 67 interviews. We also spoke with 20 minutes of meetings, staff records, results of surveys and patients who were using the hospital at the time of the audits and complaints and incident investigations. We inspection, two relatives and seven children who were placed comments boxes at the hospital before the patients and their parents. inspection which enabled staff and patients to provide us We observed care in the outpatient and imaging with their views confidentially. departments, in operating theatres and on the wards, We carried out an announced inspection on 1-3 August and also reviewed patient records. We visited all the 2016. clinical areas of the hospital. We interviewed the management team and spoke with a wide range of staff including nurses, the resident medical

Facts and data about BMI The Runnymede Hospital

The hospital has eight consulting rooms, a treatment Staff turnover varied between core services and staff room, a phlebotomy room and a pre-assessment room. groups. The vacancy rate for inpatient nurses was 11% with a turnover rate of 31.8%, both of which are higher The physiotherapy department has four cubicles and a than other independent hospitals, but there were no gym. vacancies for inpatient health care assistants. The staff In diagnostic imaging, there were general x-ray rooms, a turnover for theatre nurses was 2.4%, which is not high in mammography room, an ultrasound room, a screening comparison with other independent hospitals, but the room and a reporting room. turnover of ODPs and health care assistants was 40% which is higher than the average for other. There was a There were two laminar flow theatres with separate 50% vacancy rate for outpatient nurses ((89% staff anaesthetic rooms, one minor/endoscopy theatre, a four turnover) and a 67% vacancy rate (20% staff turnover) for bedded recovery room and a sterile store and dirty outpatient health care assistants. instrument room. There were 5,097 inpatient and day case episodes of care There were 168 doctors and dentists with practising recorded at BMI The Runnymede Hospital in the reporting privileges at the hospital, although 48% of these had not period (Apr 15 to Mar 16); of these 18% were NHS funded carried out any episodes of care between April 2015 and and 82% were other funded. March 2016. Of those remaining, 15% carried out between one and nine episodes of care, 28% between 10-99, and For this time period, patients staying overnight included 8% more than 100. 18% of all NHS funded patients and 27% of all other funded patients. In April 2016 there were 16.1 Whole Time Equivalent WTE) registered nursing staff plus 14.7 in theatre and 2 in There were 33,590 outpatient total attendances in the outpatients and 8.8 WTE health care assistants plus 5.8 in reporting period (Apr 15 to Mar 16); of these 9% were NHS theatre and 1 in outpatients. The use of bank and agency funded and 91% were other funded. staff for inpatient nurses in the reporting period (Apr 15 to There were 1,311 inpatient attendances between April Mar 16) was mainly higher than the yearly average of 2015 and March 2016, 3,788 day case attendances and other independent acute hospitals, whilst for theatre 4,881 visits to theatre. nurses it was lower. In this period, the most common medical procedures were Image-guided injection(s) into joint(s) (577),

10 BMI The Runnymede Hospital Quality Report 25/01/2017 Detailed findings

Diagnostic oesophago-gastro-duodenoscopy (OGD) was undertaken by the hospital and this was reviewed includes forceps biopsy, biopsy urease test and dyespray during the course of the inspection. There were no (468) and Diagnostic colonoscopy, includes forceps reported serious injuries in this period, and one biopsy (463). unexpected death. The most commonly performed surgical procedures were There was a total of 170 clinical incidents in the reporting multiple arthroscopic operation on knee (238), primary period (Apr 15 to Mar 16). Of these, 86% (147 incidents) repair of inguinal hernia (119) and diagnostic endoscopic occurred in surgery or inpatients and 5% (eight incidents) examination of the bladder (83). in other services. The remaining 9% of all incidents occurred in outpatients and Diagnostic Imaging (15 The hospital's PLACE scores are the same or better than incidents). The rates of clinical incidents (per 100 bed the England average for: days) in surgery, inpatients and other services are similar • Cleanliness (99% compared to 98%) or lower than other independent acute providers. • Condition, Appearance and Maintenance (93% to 92%) VTE (venous thromboembolism) screening rates were above 95% (the target rate for NHS patients) from April 15 • Ward Food (98% to 94%) to March 16. There were no incidents of hospital acquired The hospital's PLACE scores are worse than the England VTE or PE (pulmonary embolism). average for: There were no safeguarding concerns reported to the • Dementia (76% to 81%) CQC in this period. • Food (89% to 93%) There were no complaints about the hospital made to the CQC in this time period. There were 35 self-reported • Organisational Food (79% to 92%) complaints in the reporting period which is a decrease • Privacy, Dignity and Wellbeing (82% to 87%). from 2014/15 when there were 41 complaints. No complaints have been referred to the Ombudsman or From April 2015 to March 2016, there were no incidents of ISCAS (Independent Healthcare Sector Complaints MRSA or MSSA, no incidents of Clostridium difficile and Adjudication Service) in this reporting period. The rate of three incidents of E-Coli. complaints per 100 day case and inpatient attendances is There were three surgical site infections (SSI) in the not high when compared to other independent acute period April 2015 – March 2016 and the rate of SSIs (per hospitals. There are four items of rated feedback on the 100 surgeries) for primary hip arthroplasty is higher than NHS Choices website for this hospital; three rated as the average of NHS hospitals. extremely likely to recommend and one rated as extremely unlikely to recommend. There was one never event reported in September 2015. A never event is a serious incident which is wholly No whistleblowing concerns have been reported to the preventable and has the potential to cause serious CQC in the last 12 months. patient harm or death. A root cause analysis investigation

Our ratings for this hospital

Our ratings for this hospital are:

11 BMI The Runnymede Hospital Quality Report 25/01/2017 Detailed findings

Safe Effective Caring Responsive Well-led Overall

Medical care Good Good Good Good Good Good

Requires Surgery Good Good Good Good Good improvement Outpatients and Good Not rated Good Good Good Good diagnostic imaging

Overall Good Good Good Good Good Good

Notes 1. We are will rate effectiveness where we have sufficient, robust information which answer the KLOE’s and reflect the prompts.

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Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

place to mitigate. There were 1,297 endoscopy Information about the service procedures carried out in the period April 2015 to March 2016. These were mainly upper and lower gastrointestinal The BMI Runnymede Hospital is an independent hospital (GI), as well as pain treatment. which forms part of the BMI Healthcare Limited Group. It is situated in the grounds of St Peter's Hospital, Chertsey The hospital clinical team is made up of medical staff, and linked to St Peter's by a corridor. The hospital nurses and a resident medical officer (RMO) who is on provides services for privately funded and NHS patients. duty 24 hours a day. A senior nurse is available at all times to assist patients following discharge and to Paediatric patients were not admitted for medical care. arrange admissions for patients who require Young people aged over 16 were seen for endoscopy as hospitalisation for unplanned surgical treatments. We day cases. spoke to 13 consultants and staff, including nurses and The hospital did not provide us with exact numbers of members of the housekeeping, medical records and medical patients for the data period April 2015 to March administrative teams. 2016. During the inspection we were told that there were There was only one inpatient during the period of approximately four or five medical and elderly patients inspection for us to speak to. Four patients were admitted each week, but not necessarily every week. We contacted to ask for their permission for us to speak to saw evidence that for the four weeks from 27 June to 24 them afterwards, but only one responded. As a result of July 2016 there were three, four, five and four admissions, this, following the inspection we spoke with one respectively. This would equate to just over 200 patients a discharged patient and their spouse by telephone. year. Patients were admitted either from home or from the adjoining NHS hospital for reasons such as elderly The BMI Runnymede Hospital is an independent hospital care, chest infections, cellulitis, leg ulcers and anaemia. which forms part of the BMI Healthcare Limited Group. It This report is based primarily on the current endoscopy is situated in the grounds of St Peter's Hospital, Chertsey service and not on the hospital’s plans for future and linked to St Peter's by a corridor. The hospital development of a medical service. provides services for privately funded and NHS patients.Paediatric patients were not admitted for There were limited facilities for endoscopy. An endoscopy medical care. Young people aged over 16 were seen for is a procedure where the inside of your body is examined endoscopy as day cases.The hospital did not provide us using an endoscope a long, thin, flexible tube that has a with exact numbers of medical patients for the data light source and a video camera at one end. These period April 2015 to March 2016. During the inspection we facilities did not have Joint Advisory Group (JAG) were told that there were approximately four or five accreditation. However, there were effective processes in medical and elderly patients admitted each week, but not necessarily every week. We saw evidence that for the

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four weeks from 27 June to 24 July 2016 there were three, four, five and four admissions, respectively. This would Summary of findings equate to just over 200 patients a year. Patients were admitted either from home or from the adjoining NHS We rated medical care at BMI The Runnymede as good. hospital for reasons such as elderly care, chest infections, This is because: cellulitis, leg ulcers and anaemia. This report is based • Staff demonstrated a clear understanding of incident primarily on the current endoscopy service and not on reporting and there was an effective process which the hospital’s plans for future development of a medical ensured that thorough investigations were service.There were limited facilities for endoscopy. a long, undertaken with learning shared throughout the thin, flexible tube that has a light source and a video hospital. Staff could describe the duty of candour camera at one end. These facilities did not have Joint and we saw evidence of how this had been applied in Advisory Group (JAG) accreditation. However, there were practice. effective processes in place to mitigate. There were 1,297 • Staff were supported in doing both their mandatory endoscopy procedures carried out in the period April training and undertaking additional training for 2015 to March 2016. These were mainly upper and lower development. Staff spoke highly of the support they gastrointestinal (GI), as well as pain treatment.The received from managers to do this. hospital clinical team is made up of medical staff, nurses • All medical staff who treated children were trained to and a resident medical officer (RMO) who is on duty 24 safeguarding level three and the hospital had good hours a day. A senior nurse is available at all times to links with the local safeguarding teams. assist patients following discharge and to arrange • Despite some difficulties in recruiting which had led admissions for patients who require hospitalisation for to a higher level of bank and agency nurse use, unplanned surgical treatments. We spoke to 13 patients told us that the care they received was good, consultants and staff, including nurses and members of with staff taking the time to explain and reassure. the housekeeping, medical records and administrative • The Medical Advisory Committee met regularly and teams.There was only one inpatient during the period of provided input and challenge where appropriate. inspection for us to speak to. Four patients were • Although there were challenges around the physical contacted to ask for their permission for us to speak to environment in endoscopy which meant it could not them afterwards, but only one responded. As a result of achieve JAG accreditation, these issues had been this, following the inspection we spoke with one raised on the risk register and there were measures in discharged patient and their spouse by telephone. place to mitigate potential risk.

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• For the same time period, the rates of clinical incidents Are medical care services safe? (per 100 bed days) in surgery, inpatients and other services were similar to or better than other Good ––– independent acute providers CQC holds this type of data for. We have rated the safety of medical services as good. This • The hospital reported that 147 (86%) of the 170 clinical is because: incidents for the same period occurred in surgery or inpatients. It was not possible to identify any inpatient • Staff had a good understanding of incident reporting incidents for medical patients in the data provided. As and the small number of clinical incidents that had there were a very low number of medical patients occurred in the service were investigated thoroughly admitted to the hospital, we requested more recent with learning shared appropriately within the data. The hospital stated that seven clinical incidents department. had occurred in respect of medical patients between • Equipment was properly serviced and maintained with January - August 2016. clear records kept. • The hospital used a paper based document for • Medical records were available and stored safely and reporting incidents . All completed incident forms were securely. entered onto a web based database by quality and risk • All medical staff that treated children were trained to department staff. Where an investigation was required safeguarding level 3 in line with current intercollegiate this was led by the appropriate head of department with guidance. 20 days to complete and return the investigation form. • There were effective systems in place to support staff in • Any learning resulting from incident investigation was completing their mandatory training and an overall disseminated throughout the hospital with reports sent completion rate which placed them fifth out of 59 BMI to various committees. These included clinical hospitals. governance, medicines management, the medical However: advisory committee (MAC), health and safety and water safety. • The endoscopy service was not JAG accredited, • Themes were looked at to improve learning across the although there were measures in place to mitigate risks hospital. and manage the service appropriately. • Staff we spoke with in the various areas we visited on Incidents the inspection were all able to describe the reporting process and the feedback at ward and departmental • There were no never events in medicine in the period meetings. We also saw feedback on an investigation in April 2015 to March 2016. Never events are serious the April 2016 team brief. Dissemination of feedback in incidents that are wholly preventable as guidance or this way ensured that all staff learnt from incidents to safety recommendations that provide strong systemic help prevent a recurrence. protective barriers are available at a national level and • Endoscopy staff were aware of the incident reporting should have been implemented by all healthcare process. The theatre manager signed off every incident providers. The occurrence of a never event could and investigated where required. We were told that indicate unsafe practice. there had been no harm to patients from known risks • BMI Healthcare Limited, the provider company, sent such as oesophageal perforation, (Anoesophageal examples of any never events that occurred at any of perforationis a hole in the tube that food and liquids their hospitals to all hospitals for discussion and action pass through on the way from your mouth to your where relevant. stomach, which can occur following an injury during a • The hospital reported four patient deaths for the period medical procedure), no returns to theatre and no April 2015 to March 2016 of which there were no incidents of post procedure bleeding. All incidents were unexpected deaths in medicine. discussed at the clinical governance meetings, heads of • No incidents were reported as leading to “severe” harm department meetings and the MAC. The theatre in the period April 2015 to March 2016. manager attended all these committees.

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• Staff we spoke with demonstrated knowledge and • The patient-led assessments of the care environment understanding of the duty of candour (DoC) under the (PLACE) scores for cleanliness and condition, Health and Social Care Act (Regulated Activities appearance and maintenance were marginally better Regulations) 2014. The DoC is a regulatory duty that than the national average, for example 99% against 98% relates to openness and transparency and requires for cleanliness. providers of health and social care services to notify • The patient and relative we spoke with following the patients (or other relevant persons) of “certain notifiable inspection felt that cleanliness was of a high standard. safety incidents” and provide them with reasonable Environment and equipment support. There had been an issue with a specific piece of equipment and the consultant ensured that the • We saw evidence that the endoscopy equipment had patient was informed and a full discussion undertaken. been serviced with a log book kept in the unit. This There was no harm to the patient. provided assurances that it was safe and fit for purpose. • We saw examples of weekly checks carried out in the Safety thermometer or equivalent (how does the unit such as water samples, silicone oil to scopes and service monitor safety and use results) valves and lens cleaners. • The hospital used the NHS Safety Thermometer, a • We saw daily checks completed and when there was national improvement tool for measuring, monitoring either no endoscopy session, or at a weekend, this was and analysing harm. It measured the proportion of also clearly documented. patients that experienced ‘harm free’ days from • The sharps bin was dated, signed and used in pressure ulcers, falls, urinary tract infections in patients accordance with the Health and Safety (Sharp with a catheter and venous thromboembolism. Instruments in Healthcare) Regulations 2013. Safe • We saw the results for the safety thermometer from May disposal of sharp objects such as needle sticks helped 2016 which showed that there had been no falls, no protect staff against injury. There were two suction urinary tract infections, no VTEs and 100% of patients machines in the lifts. One had an expiry date of April had been assessed for VTE. 2017 and the other July 2017 and had been serviced in • Day case patients were excluded from the safety July 2016. thermometer. • We looked at various pieces of portable equipment and • We saw safety thermometer data displayed in hospital saw that these had been checked annually, for example areas which showed information about incidents and eight blood pressure machines. patient satisfaction. • In the dirty utility, we observed visibly clean commodes which had been labelled to indicate they had been Cleanliness, infection control and hygiene cleaned. • No episodes of hospital infections of • Resuscitation trolleys were available at the entrance to methicillin-resistant Staphylococcus aureus (MRSA), both wards with oxygen. We reviewed the checklists for Clostridium Difficile (C. difficile) or methicillin sensitive both paediatric and adult resuscitation trolleys and Staphylococcus aureus were reported between April confirmed that these had been fully checked for the last 2015 and March 2016. three months. • The hospital reported three incidents of Escherichia coli • We found that the endoscopy unit was not working (E. coli) in the same time period; we saw that a full Root towards the Joint Advisory Group on gastrointestinal Cause Analysis had been completed for each infection. endoscopy (JAG) accreditation as the environment and • Personal protective equipment such as gloves and facilities would not reach the necessary standards to aprons were readily available in all clinical areas we achieve it. The hospital and staff were aware of this and visited. This allowed staff to protect themselves and there had been a proposed new build put forward some patients against infections. years ago. BMI Healthcare at a corporate level was working with the local NHS trust to develop this proposal as they own the land the hospital is on.

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• Staff followed the Choice Framework for endoscopy, • The sample medicines we looked at on two drug trolleys now superseded by HTM -1-06, for decontamination of and drug cupboard were in date. All syringes and flexible endoscopes. There were corporate policies consumables were in date. Anaphylaxis kit was available developed by the BMI Healthcare endoscopy group. on both wards. • The decontamination room was very small with three • We checked fridge temperature records on the ward and old washers. The sinks were very close to the washers found they were all correct. Staff checked the medicines and it would be difficult to avoid microbial spray which fridge when the ward was open, and the fridge was not could spread infection. The decontamination facilities used when the ward was closed. were on the health and safety risk register and the Records potential issues were well known. There was a standard operating procedure for managing the decontamination • The hospital told us that relevant medical records were area which mitigated the risks posed by this. available for all patients admitted over the previous • The risks were mitigated by the robust controls put in three months. place by the lead endoscopy nurse. We saw that the • We saw that the theatre register for endoscopy patients daily cleaning and individual washer water checks were was well completed. This increased patient safety by completed as well as weekly endoscopy check list. The ensuring that there were accurate and unit adhered to the British Society of contemporaneous records of patients. Gastroenterologists (BSG) guidelines for endoscope • We saw that patient records were securely stored in cleaning. We saw records which demonstrated that daily lockable filing cabinets in an office with a key code. This and weekly checklists had been appropriately ensured the hospital protected patients’ personal and completed. confidential data in line with The Data Protection Act • There was a risk assessment in respect of the washers. 1998. The health and safety link nurse in theatres worked • For NHS patients being treated as part of any waiting list closely with the endoscopy lead for risk assessments initiative, the NHS medical records were requested and associated with this area. There was a contingency plan copies of all records for the episode of care, including should any washer break down. the discharge summary, were filed in the NHS records • Each endoscope was pre-checked before use to ensure before returning them to the relevant NHS trust. This that equipment was safe to proceed. allowed continuity of care and assisted with clinical • We saw evidence that the equipment was properly decision-making. serviced and maintained. The endoscopy lead attended • NHS medical records were stored in lockable filing a manufacturer’s endoscopy day and was due to attend cabinets whilst the patient was at the hospital. another. The endoscopy lead could access advice and • For NHS patients referred through Choose and Book, support from the providers of the equipment and said BMI hospital records were made up for the episode of they felt well supported by line management. care with the discharge summary sent to the GP, or other referring doctor. Choose and Book is a national Medicines electronic referral service which gives patients a choice • We found that medicines were managed well in the of place, date and time for their first outpatient endoscopy unit. We saw that the controlled drugs appointment in a hospital or clinic register was well completed with no omissions. • All patient records held by the hospital were scanned for Controlled drugs are certain prescription only medicines archiving 10 months after the last activity. This meant which are controlled under the Misuse of Drugs they were available post treatment and could be legislation and include morphine and pethidine. We saw recalled if required after that. that the stock check was correct which meant that • We were told that all consultants were registered with controlled drugs were being stored safely and securely the Information Commissioner’s Office (ICO) which which reduced the risk of patient harm. meant that they had appropriate arrangements in place • Three monthly pharmacy checks took place and where to store confidential patient information safely and issues were found, action plans were developed. securely.

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Safeguarding board’ comparing the hospitals and we saw that the Runnymede Hospital was fifth out of 59 hospitals with • The director of clinical services was the hospital over 92% completion rates. This made them the highest safeguarding lead for both vulnerable adults and in the south region. children. The director also chaired the BMI National • We found good systems and processes in place that Children and Young Persons’ Committee. supported staff in completing mandatory training with • One hundred per cent of medical staff, including the information about relevant courses available to them Resident Medical Officer (RMO), who treated children, both in the hospital and at other nearby BMI hospitals. were trained to Safeguarding Level 3 as were the Managers responsible for staff mandatory training were paediatric nurses. This was an appropriate level of kept fully informed of attendance and completion. training in line with national intercollegiate guidance. • Mandatory training was electronically reviewed on a The hospital had worked closely with visiting weekly basis by training topic. Where there were any consultants to ensure training was up to date and we concerns lists would be sent to the relevant heads of saw the hospital’s list of consultants who could treat department. We saw that the hospital had 100% children at Runnymede Hospital. compliance for topics such as blood transfusion, • The hospital had links with the local safeguarding teams medical gases and medicines management. Paediatric and was represented by the Clinical Commissioning basic life support had 64% compliance and we saw that Group’s safeguarding lead on both the children’s and emails had been sent to staff with information about adult safeguarding boards. relevant courses at the hospital and also at other nearby • The care of children was discussed at the monthly BMI hospitals. We saw forms for staff to complete should clinical governance meeting, and staff received they complete e-learning elsewhere as well as copies of supervision and support. attendance registers for courses that included a • Staff told us that no children under 16 years old were practical session. treated in the endoscopy unit. The unit was in theatres • Staff we spoke with told us they had completed their and theatre staff were trained to Level 2, which was not mandatory training. We saw evidence of completed in line with national guidance for working with children. training such as equality and diversity, fire, and first aid. However, only consultants on the hospital list would be • The RMOs were supplied by an agency. The RMOs able to undertake procedures on children up to 18 years completed all mandatory training through the agency of age and they were appropriately trained to Level 3. and recorded this on their CVs. The hospital checked the • There was a robust process to ensure that only agency documentation for assurances that RMOs were consultants with the appropriate level of safeguarding fully compliant with mandatory training before they training were able to see children and young people as started work. patients. • We saw that the risk assessment for admitting 16 to 19 Assessing and responding to patient risk year olds had been reviewed in May 2016. • We saw evidence in the four medical records we looked • The hospital reported no safeguarding concerns to CQC at of risk assessments such as skin viability, nutrition for the period April 2015 to March 2016. and falls. For patients at risk of falling there was a variety • There were laminated flow charts for staff, should they of equipment available to mitigate the risk such as mats have a safeguarding concern, available in all clinical and ‘high/low’ beds. areas we visited. These included where to seek advice • The hospital used the national early warning score within the hospital and all relevant contact numbers for (NEWS) charts for tracking patients’ clinical conditions social services and the police. These had been and alerting the clinical team to any deterioration that developed over the last two years and had helped staff would trigger timely clinical response. We saw variable to know how to flag concerns. completion of the NEWS sheet. We saw examples of Mandatory training good recording and examples where it was not always used as designed. We noted one record where a score • BMI Healthcare provided weekly reports to all hospitals should have prompted hourly checks but this had not of the mandatory training rates. This included a ‘leader

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happened. This made identifying when to escalate that all BMI hospitals completed to analyse and monitor appropriately more difficult as the NEWS score was not staffing. The review included the minimum skill mix correct in every case. We were told that there was required for the various patient groups such as medical ongoing training for staff to improve use. patients and elderly care. • Any concerns regarding communicable diseases would • There was variable use of bank and agency staff for be identified at pre-assessment for patients to be inpatient nurses for the period April 2015 to March 2016. admitted to the ward or for endoscopy. Staff would This meant the rates were mainly worse than the yearly liaise with the infection prevention and control nurse to average of other independent acute hospitals CQC agree the way forward. The team would be informed at holds this type of data for. However, there was low use team briefings and the consultant made aware. of bank and agency staff in respect of health care • The RMO provided medical cover 24 hours a day, seven assistants for the same period. days a week. This meant concerns regarding a patient • The one patient and relative we spoke with both said could be escalated at any time of the day. The RMO there felt there were sufficient staff on the ward during could contact the relevant consultant as they were their stay. required to be available at any time of day when they • However, staff told us that whilst most agency staff used had patients admitted to the hospital, or to make were regulars they felt more permanent staff were arrangements for cover. Staff told us this happened. needed. • There was a service level agreement in place with the • There was a senior nurse available at the hospital as a local NHS hospital for specialist advice regarding contact point for both staff and patients, including to deteriorating patients such as intensivist, help resolve patient queries and to accept out of hours microbiologist, cardiologist and pharmacy. admissions. • We saw the joint transfer protocol between the hospital • In addition to clinical and consultant arrangements, the and the South East Coast Critical Care Operational senior management team operated a rota for on call Delivery Network. This meant that patients would be support out of hours. There was also an on call rota transferred to the nearest NHS hospital with an available operated by the pharmacy, radiology and physiotherapy critical care bed should they suffer, for example, a teams should support be required out of hours, as well stroke. as an on call emergency theatre team. • We were informed that screening rates for venous Medical staffing thromboembolism (VTE) for the period April 2015 to March 2016 were above 95%. There were no reported • Consultants were required under their practicing incidents of VTE or pulmonary embolism for the same privileges to be available both by telephone and, if period. required, in person whenever they had patients admitted to the hospital. Consultants were required to Nursing staffing arrange appropriate alternative named cover if they • We were told that the BMI Healthcare nursing would not be available. Since many of the consultants dependency and skill mix tool is a guide to ensure the worked at the adjoining NHS hospital, staff told us it was right members of staff are on duty at the right time and easy to contact them when needed. with the right skills, to ensure high quality patient care. • An RMO, supplied by an external agency, provided a 24 The tool was used to plan the skill mix five days in hour seven day a week service on a rotational basis. The advance with review and updates on a daily basis. RMO worked closely with the consultants in the care of • BMI Healthcare carried out a review of the corporate the patients. Should the RMO become unwell the nursing establishment tool in 2014. This affirmed that, agency was called to provide cover. “Professional and clinical judgement will always • We saw the corporate BMI Healthcare Practicing determine the best possible nursing intervention for Privileges Policy for Consultant Medical and Dental patients admitted or attending a BMI Healthcare Practitioners, 2015. Adherence to the policy was Facility.” We saw examples of the monthly spreadsheets monitored and we saw minutes which showed that any concerns were discussed at the Medical Advisory Committee.

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Major incident awareness and training • We saw that endoscopic procedures were carried out in line with professional guidance. • As the hospital was linked by a corridor to the local NHS • There was a system for alerts received from the hospital, staff formed part of their major incident team Medicines and Healthcare Products regulatory Agency with an emergency policy in place. (MHRA) that could be cascaded through the hospital. We • The hospital had a business continuity policy in line saw that these were discussed at the clinical with ISO 22301 Business Continuity Management governance meetings in sample minutes that we looked Systems Requirements. We saw the individual guidance at. sheets for emergencies such as loss of the fire alarm • There was a BMI Healthcare policy for cannulation system, loss of IT systems and water leak/internal flood. insertion, management and removal. The policy stated All included relevant contact numbers. All policies and that a cannula should be re-sited before 72 hours in line protocols were on the hospital’s shared IT system as with national guidance. In section 15.6 the policy stated, well as paper copies in folders on all wards. “The maximum time in situ should be no more than • There was a backup generator that started up after 15 96hrs”. This equated to four days. One patient who had seconds. We were told that this was tested monthly to transferred from surgical to medical care had the ensure continued power in the event of a loss of mains cannula in situ for five days and we found some lack of electricity. clarity regarding this policy. However one nurse we • The hospital provided scenario-based training exercises spoke with demonstrated good knowledge and which included five paediatric and five adult understanding of the policy and practice. resuscitation exercises a year. This enabled staff to keep their resuscitation skills up-to-date and staff told us they Pain relief found them useful. • Patients’ pain was recorded on the National Early Warning Scores (NEWS) chart. The NEWS chart is a Are medical care services effective? standardised chart for assessing and responding to acute illness. Good ––– • We heard from a patient that pain management was good, and that staff asked about their pain on a regular We rated effective as good. This was because: basis. • Pain relief was audited via patient satisfaction surveys to • There was a comprehensive system of audit and monitor the way that staff assessed and explained pain provider visits (an internal BMI audit process to monitor to patients and the pain relief that was then offered. We quality of care) to drive continuous improvement. saw the February 2016 audit which showed results for • Audits of pain management showed high levels of the previous six months. These showed that staff asked compliance with policy around pain relief with staff 100% of patients about their pain on admission, 100% explaining to patients the level of pain they might had their pain score, where appropriate, assessed on expect and how this would be managed. the relevant chart at least every four hours, and 100% of • Staff competence was ensured through comprehensive patients had pain management planned and evaluated induction and regular and effective appraisals. throughout their stay. Evidence-based care and treatment Nutrition and hydration • Provider visits audited the endoscopy unit. We saw that • We saw information regarding starving times provided the Scope Plus Audit Trail log books were completed. for patients booked for endoscopy procedures. These This is a system which enables the user to track the patients were admitted as day cases. decontamination of an endoscope through manual • There was one medical patient on the ward during the wash, automated reprocessing, storage and finally to inspection. They told us that the food was of a good use on a patient. Completion of the log books gave quality and nutritious. They were well provided with hot assurance that the endoscope was safe and ready for and cold drinks during their admission. We were told use. there was a, “personal touch to everything [staff] do.”

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• Catering services were outsourced and there had been a • There was always a member of staff on shift who had change to another private provider. The Patient-led been trained in Advanced Life Support. assessments of the care environment (PLACE) for the • We saw that paper work relating to practising privileges period February to June 2015 showed that some food was stored securely, with consultant information, such measures scored 89%.This was worse than the national as appraisals and indemnity details, uploaded onto a average of 93%. However, ward food scored 98%, which corporate database. This ensured that any missing was better than the national average of 94%. paperwork was chased up in a timely manner to • We were told that the hospital were working with the maintain compliance with BMI requirements. catering services to improve patient satisfaction and we • We saw the list of consultants who had been approved saw evidence in clinical governance committee minutes to provide care to children. These required level three of continued ways to improve being discussed. safeguarding training and specific paediatric training. • Applications for practising privileges were reviewed by Patient outcomes the MAC chair and signed off by the MAC. • Patient outcome data was compared with all hospitals • All theatre staff had been trained on manual across BMI Healthcare using the corporate clinical decontamination for the endoscopy service. The dashboard that gathered data from the group incident relevant senior staff had attended an endoscopy database and patient satisfaction surveys. Overall, BMI decontamination course for managers. The Runnymede Hospital at the time of the inspection Multidisciplinary working ( in relation to this core stood at 41 out of 59 locations. service) • The hospital had a robust audit programme with audits completed online via the hospital audit calendar, and • We were told that patients were not admitted for end of results discussed at the clinical governance committee life care and that there was no end of life care pathway. and departmental meetings. These included However, we saw that a patient admitted directly from documentation and consent audits for paediatric outpatients for medical care was subsequently provided patients. with end of life care. We saw that there was good input • The endoscopy service was not JAG accredited. The BMI by the palliative care team from the adjoining NHS strategy was to achieve JAG accreditation for all hospital. endoscopy services but staff acknowledged this would • We saw examples of joint surgical and medical care not be possible given the environment at the where a patient was ready for discharge following Runnymede. surgery but had a medical condition so was passed to the care of a physician. Competent staff Seven-day services • The agency that supplied the RMO provided the CV for a new RMO and this included their training records. Each • The hospital had medical cover from an RMO and senior new RMO undertook a full hospital induction. nurse 24 hours a day, seven days a week as a contact • We were told of opportunities for development such as point for both staff and patients. undertaking a mentorship course. This meant that staff • Patients had access to telephone advice from nursing were able to progress within the organisation. staff 24 hours a day, seven days a week. • Registered and non-registered nursing staff undertook • There was also an on call rota operated by radiology acute illness management training which meant they and physiotherapy teams should support be required were able to identify clinical deterioration in patients. out of hours, as well as an on call emergency theatre • We were told of recently introduced speech and team. language therapy training such as swallowing to Access to information support staff in caring for medical patients. A senior nurse had attended this training. • There were electronic systems that recorded all patients • Staff had annual appraisals as well as a mid-year review. booked into outpatients, day case and inpatients. We were told that these were useful and identified additional learning needs.

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• Pre-assessment included past medical history, allergies and other patient information. This meant that staff Are medical care services caring? were prepared for the patient when they arrived and could manage their care safely and effectively. Good ––– • The National Enquiry Centre allowed staff to access the diary of any consultant so that appointments could be We rated caring as good because: booked appropriately and without delay. • Policies were available on the intranet for staff to access • Although we were not able to speak to a large number and a regular Team Brief was circulated to all staff to of patients, the comments cards and the small number inform them of key updates and developments. we spoke to reported excellent and compassionate care • Any significant changes in policy or practice were from staff. emailed to consultants with practising privileges and • We observed clinical and non-clinical staff respecting they were asked to confirm receipt and acknowledge the privacy and dignity of patients. that they had read the information. • There were well established links with the adjoining • Medical secretaries typed letters to the GP following the NHS hospital to provide spiritual support for patients patient’s attendance. where required. • Pathology services were provided under a service level Compassionate care agreement with the adjoining NHS hospital and an electronic link between the laboratory and the hospital • We spoke with the only inpatient under medical care at ensured results were available in a timely manner. the time of our inspection. They told us that staff protected their privacy and dignity, and were courteous Consent, Mental Capacity Act and Deprivation of and caring. Liberty Safeguards • The patient and relative we spoke with after the • We observed staff on the ward obtaining consent from inspection told us that the staff were very caring and patients before starting care or treatment. We noted helpful. They felt their privacy and dignity were that staff explained the planned procedure and respected at all times. The relative said that the staff interacted well with the patient to obtain consent. had the time to provide very good care. • We saw that consent had been appropriately • A patient told us that call bells had been answered documented in a patient’s record. promptly and they felt they never had to wait to speak • Staff described an occasion when they had assessed to a member of staff. mental capacity at pre-assessment. • We observed that housekeeping staff protected patient • We were told that 45 out of 85 staff had received DoLS privacy and dignity. They knocked before entering the training. Deprivation of Liberty Safeguards (DoLS) relates room, introduced themselves, asked whether they could to people who are placed in care homes or hospitals for clean the room and spoke courteously with patients. their care or treatment and who lack mental capacity. • Patients who had an endoscopic procedure received a Training for staff ensures that they understand the telephone follow up call from nursing staff to check that principles and can provide safe care and appropriate they were well. treatment for vulnerable adults. We spoke to staff who • We observed nursing staff providing compassionate had received this training and they were aware of the care to a patient. principle issues, but felt they were unlikely to need to Understanding and involvement of patients and use it as the admissions screening tool would exclude those close to them patients where this might be necessary. • Patients told us that comprehensive information regarding care and treatment was provided throughout their hospital stay with staff explaining clearly the nature of tests required and the purpose of observations.

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• A relative told us that friendly staff had provided them • Patients were booked in for pain treatment and the with lots of information and were happy to spend time details entered on to the hospital electronic system. with them to explain what was happening Pre-assessment appointment timings were discussed with the patients to accommodate their preferences. Emotional support • Patients to be admitted either had a telephone • One CQC comment card was completed by an pre-assessment or came to the hospital clinic where endoscopy patient during the inspection. They were they were seen by a registered nurse and any other very positive about the care and treatment, “especially appropriate professionals such as therapists. Any tests as I was nervous, they put me at ease.” were taken at the clinic, such as MRSA screening and • Spiritual support for patients was accessed via the blood tests. adjoining NHS hospital. • NHS patients referred through Choose and Book were • Ward rooms had both a telephone and Wi-Fi internet booked into day case and outpatient slots by the access so that patients could receive emotional support consultants’ secretaries with referral to treatment times from friends and family during their stay. checked daily. Reports were sent each month to the Clinical Commissioning Group. Are medical care services responsive? • Patients told us they had been seen on time. • As far as possible, people were able to access care and Good ––– treatment at a time to suit them with flexibility around appointment times. • The hospital had clearly defined criteria for medical We rated medical services as good for responsive admissions which used a score chart to assess a because: patient’s suitability, and took into consideration their • Pre-assessment appointment times were discussed mental state, mobility and falls history. with patients to ensure that their preferences and needs • Two patients both reported that they felt their could be accommodated. admissions had been well planned and that the hospital • Although the numbers of patients living with dementia had been responsive to their needs. were very low, all 83 members of staff had received Meeting people’s individual needs dementia training. • Complaints were investigated thoroughly and learning • Whilst we were told that the hospital did not admit shared from these at departmental meetings. many patients living with dementia we saw that all 83 • The hospital had arrangements in place to provide members of staff had received dementia training. This interpreters, including sign language interpreters, if included registered and non-registered nurses, theatre needed. staff, physiotherapists and radiographers. This meant staff had the necessary training to enable them to better Service planning and delivery to meet the needs of meet the needs of patients living with dementia, local people • Although staff could not articulate a clear policy around • NHS patients accounted for about 18% of total inpatient the age limit for endoscopy, we reviewed records and and day case activity. This was significantly different to found no examples of children under 16 years of age the average across all BMI hospitals where 45% of undergoing endoscopy procedures. Staff told us that patients are NHS-funded. should that be required, the endoscopy unit was in • There were very few medical patients admitted over the theatres with staff trained to work with children and only last 12 months although the hospital was unable to consultants on the hospital’s list of those authorised to provide us with exact numbers. treat children would be able to undertake an endoscopic procedure. Access and flow • As there was only one medical inpatient during the inspection visit, the hospital wrote to four recently

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discharged patients. They included a reply paid • Clinical governance meetings had clear oversight of envelope and requested consent for CQC to contact incidents and complaints with thorough investigations them to share their experience. One patient responded and dissemination of learning. and was contacted by CQC after the inspection. • The medical advisory committee had a robust structure • The patient and relative we spoke with following the and meeting minutes demonstrated constructive inspection said that staff were quick to respond to the debate and thoughtful decisions. call bell, or any request for assistance. • There was a register of languages that hospital staff Vision and strategy for this this core service spoke so that they could be asked to interpret if • There was an overarching BMI Healthcare strategy that required. Staff knew how to access this and could also all hospitals worked to which was developed use the translation line in operation at the adjoining corporately. NHS hospital if needed. • The local vision and strategy stated that Runnymede • The hospital had a contract with an external company to should be the private hospital of choice for patients and provide sign language to patients who required this to consultants in West Surrey, to deliver high quality communicate. service, be the employer of choice and to continually • Staff told us that the hospital was able to accommodate improve and update their facilities and environment. a patient’s request to have all female staff. This local mission statement was developed by the • The hospital had a feedback form for patients to use, Executive Director in discussion with the heads of and in response to comments from children had department. developed a separate comment form for children to use. • Staff we spoke with were aware of and understood the Learning from complaints and concerns vision. • There was a plan to increase medical services and • We saw the hospital complaints policy. The lead within develop ambulatory care. the area receiving the complaint would be informed and commence an investigation. The leads contacted the Governance, risk management and quality complainant where possible and offered face to face measurement for this core service meetings. We saw evidence that complaints were • There was a corporate strategy for governance that investigated and acted upon. They were discussed at provided a framework for local governance procedures. appropriate committees and the daily huddle. We saw • There were a variety of monthly meetings that discussed that 95% of complaints were responded to within 20 risk, incidents and complaints. These included the days, which was the hospital target. Learning from senior management team and heads of department complaints was shared through team briefings and meetings. Information from these meetings was team meetings. disseminated to ward meetings. In turn, information • We were told that the main themes for complaints were from the departmental meetings was fed up to the finance, communication and the time spent with heads of department. This ensured that there was good consultants. communication throughout the hospital and staff were aware of specific incidents and causes for concern. Are medical care services well-led? • The hospital had a clinical governance committee (CGC) which met every other month. We saw samples of Good ––– minutes that demonstrated that departmental and other meetings fed into the CGC such as theatre and We rated medical care services as good for well led ward meetings, patient experience committee and because: resuscitation committee. Clinical quality as well as governance was discussed at the quarterly Medical • We saw evidence of good team working. Advisory Committee (MAC) meetings. • The senior team was visible, approachable and • Ward meetings were held every other month and supportive to junior staff. minutes we looked at showed discussions on topics

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such incidents and infection prevention and control. • Daily communication meetings (‘huddles’) were held Night staff meetings were held quarterly. The ward with representatives from all departments to discuss the manager attended. We looked at the minutes for July previous day’s activities and plan for the day ahead. This 2016 and saw that the executive director also attended. meeting also allowed senior staff to raise concerns and Items included recent audits, complaints, completion of report on incidents and complaints, where relevant. NEWS score sheets and recruitment. • The lead for the endoscopy service clearly described the • Each clinical area had a blue clinical governance folder systems in place to mitigate the risks identified because that included emergency contact numbers, protocols of the environment, and demonstrated effective such as urgent admissions, safeguarding flow charts processes to assure staff competency and learning from and duty of candour. These were visible and easy to incidents throughout the department. access. • We saw minutes of team meetings which showed that • We were told there were 61 regular visiting consultants incidents were discussed and learning shared to help out of a total of 168. Consultant contracts, known as prevent recurrences. practicing privileges, were managed jointly by the • Staff told us they felt supported by managers, and were hospital management and the MAC. There was also encouraged around the completion of personal evidence of consultants suspended when they had not development. provided the required documentation requested by the • All staff we spoke with felt that the senior management hospital management and reinstated once they had. team were approachable and visible. We saw good This demonstrated the hospital had robust procedures attendance at various committees. to ensure all consultants were competent and fit to care • Staff told us that there had been a lot of work to for patients. improve incident reporting and create an open culture. • We saw that an extensive information pack was They felt this had now been achieved and were able to prepared and circulated prior to the medical advisory raise concerns with both immediate line management committee meetings. The pack included all incidents, and the senior team. root cause analysis investigations, complaints and audit • The management team was addressing difficulties in results. This provided comprehensive information for recruitment and retention of staff by ensuring that discussion and allowed those attending to prepare for salaries matched both their independent competitors the meeting and spend the meeting time effectively. We and NHS trusts. Training and development were offered saw from the minutes of MAC meetings that there was to staff to retain them, including a management and constructive debate and challenge to investigations leadership course. where appropriate. We looked at the February to April Public and staff engagement 2016 clinical governance report for the MAC and saw there were two incidents in respect of medicine. • Senior nursing staff ran workshops for the nursing teams • No whistleblowing concerns were reported to CQC in to support individuals in the re-validation process. the last 12 months. • Nursing staff had access to training and development to • However, we were told of a member of the nursing staff promote retention of staff, and last year there was a pay who had given prescription only medicines at night review to ensure that salaries were comparable with without prescription, and had repeated this despite NHS pay scales. receiving additional training. We raised our concern at • There were regular staff forums and a more formal ‘team the time of the inspection with senior managers and brief’ to ensure that staff were kept aware of they took immediate action to be assured of safe developments and updates. processes regarding administering medicine at night. • Patient satisfaction scores were consistently high, with • The endoscopy environment was highlighted as one of 98% (of 410 responses) in June 2016 rating the hospital the key clinical risks within the hospital and there were as either very good or excellent. measures in place to mitigate this. Innovation, improvement and sustainability Leadership and culture of service

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• We were told of plans to have four dedicated medical • There was a rolling programme to replace flooring (from beds from September 2016. Five physicians were carpet to laminate) and redecorate. involved in planning the increased medical service provision.

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Surgery

Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

All children up to 16 years are cared for by two registered Information about the service children's nurses. The service is supported by the lead children's nurse and specialist paediatric clinical advice Surgical services cover a range of adult specialties and support is provided by the lead paediatrician who is including orthopaedics, ophthalmic (eye), urology, general based at a local NHS hospital. and gynaecology surgery. On Burwood ward, four twin-bedded rooms were allocated Pre-planned elective surgery services are also provided to close to the nurses’ station for children and young people children and young people between the age of three and requiring inpatient or day care surgery. There was an 18. Invasive procedures are not performed on children allocated recovery area for children in theatres. A small under the age of three. The hospital does not accept supply of children's toys was available, including children's emergency children’s admissions. channels on TV, a DVD player and a children's menu was Between April 2015 and March 2016, there were 4,881 adult provided. visits to theatre. The most common procedure undertaken The theatre suite has three operating theatres, four was arthroscopy of the knee (238) (a technique in which a recovery bays and two anaesthetic rooms. Theatres one tube-like instrument is inserted into a joint to inspect, and two have laminar flow (a system that circulates filtered diagnose, and repair tissues.) Repair of inguinal (groin) air to reduce the risk of airborne contamination.) A mixture hernia (119) (a hernia is a term used to describe a bulge of orthopaedic, gynaecology, vascular, general, urology and through a structure or muscle) was the second most ear, nose and throat surgery is undertaken in these common operation. theatres. Theatre three does not have laminar flow and There were 103 operations undertaken on children aged mainly undertakes local anaesthetic and sedation between three and fifteen between April 2015 and March procedures for example, endoscopy, oral surgery and eye 2016 and 28 operations undertaken on 16 and 17 year olds surgery. during the same time period. The most common operation Wentworth ward is used to care for day care patients. (22) undertaken was myringotomy and insertion of tube During our inspection Wentworth ward was not open due through tympanic membrane (a surgical procedure in to a small number of admissions; however the environment which an incision is made in the eardrum to relieve and equipment were inspected. Both inpatient and day pressure caused by build-up of fluid, a tube is inserted into care patients recover from surgery on Burwood ward. The the eardrum to keep the middle ear aerated for a hospital has 52 beds split equally across Burwood and prolonged time and to prevent re accumulation of fluid.) Wentworth wards. The majority of rooms are single, there are four double rooms and all rooms have en-suite facilities, satellite television, telephone and internet.

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We visited all clinical areas including theatres, ward areas and the preoperative assessment clinic during our Summary of findings inspection. Overall, we rated surgical services as good. This was During our inspection, we spoke with 31 members of staff because: including nurses, doctors, allied health professionals, catering staff, domestic staff, administrative staff and the • The hospital had effective systems to assess and executive team. We spoke with six patients, one patient’s respond to patient risk and we saw examples during relative and five children and their parents. We also our inspection. received 34 patient comment cards with feedback from • Staff planned and delivered patient care in line with patients who had surgery at the hospital. We reviewed 14 current evidence-based guidance, standards, best sets of patient records and a variety of hospital data for practice and legislation. We saw that the hospital example meeting minutes, policies and performance data. monitored this to ensure consistency of practice. • The hospital participated in relevant local and national audits and contributed to national data to monitor their performance such as the National Joint Registry (NJR). Staff we spoke to understood and fulfilled their responsibilities to raise concerns and report incidents and we saw examples of this. • We saw the hospital fully investigated incidents and shared learning from them to help prevent recurrences. • Patient consent was recorded in line with relevant guidance and legislation. • We saw staff treated patients with dignity, respect and kindness during all interactions. Patients told us they felt safe, supported and cared for by staff. • There was a governance structure that promoted the delivery of high quality person-centred care. • Leaders modelled and encouraged cooperative, supportive relationships among staff. The majority of staff told us they felt respected, valued and supported. • Services generally ran on time. Waiting times, delays and cancellations were minimal and the service managed these appropriately. We saw when a delay occurred there was an immediate explanation and apology. However: • There was a low percentage of staff that had undergone an appraisal in 2016, and in addition only 11% of theatre staff had an appraisal in 2015. • We saw that some of the clinical areas had carpets. • Fire doors within the theatre suite did not have intumescent strips around the edges of doors or door frames.

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• In theatres we saw three bowl stands had rusty Are surgery services safe? wheels. • We could not find evidence of an electrical safety Requires improvement ––– check on three patient trolleys. • Electrical cables in theatres were not secured. We rated safe as requires improvement because: • In theatres there was a door on one of the preparatory rooms with a faulty closure mechanism • Fire doors within the theatre suite did not have which was potentially unsafe. intumescent strips around the edges of fire doors or door frames. Intumescent strips are designed to expand under heat, and fill the gaps between the door edges and door frame, thereby preventing the passage of smoke and fire to other parts or compartments of the building. • In theatres there was a door on one of the preparatory rooms with a faulty closure mechanism which was potentially unsafe. • Medicines were used outside of the terms of use without correct approval and risk assessments. • There were ‘blanket’ signatures of controlled drugs. • In theatres we saw three bowl stands had rusty wheels. • We saw that some of the clinical areas had carpets. • There was a box of medication which contained drugs with different batch numbers. • We could not find evidence of an electrical safety check on three patient trolleys. • The World Health Organisation Surgical Safety Checklists were not always fully completed. • Electrical cables in theatres were not secured. However we also found: • Staff told us that openness and transparency about safety was encouraged. When something went wrong there was an appropriate thorough review or investigation. This involved relevant staff and people who used services. • Lessons were learnt and communicated widely to ensure improvement in other areas in addition to the services that were directly affected. Staff told us of a recent never event that had occurred and they described a no blame supportive process during the investigation. • We observed staff recognised and responded appropriately to changes in risks to patients who used services. During our inspection we saw staff respond to and take appropriate action when a patient developed a temperature prior to the commencement of a blood transfusion.

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• We saw a patient receive a sincere and timely apology advisory committee (MAC) which showed the when they were told the incorrect time to arrive at the circumstances surrounding the patient’s death had hospital for their operation. been reviewed. This meant that there was a full case • There were clearly defined and embedded systems, review and any lessons learnt could be identified. processes and standard operating procedures to keep • The hospital reported one expected death between patients safe and safeguarded from abuse. These were April 2015 and March 2016, we reviewed the patient’s appropriate for the care setting and were understood by notes and considered the care and treatment of the all staff and implemented consistently. patient had been planned for and managed • We saw staffing levels and skill mix were planned, appropriately. implemented and reviewed to keep patients safe at all • Surgical services reported 147 clinical incidents times. Any staff shortages were responded to quickly between April 2015 and March 2016, surgery reported and adequately. 86% of all hospital wide clinical incidents. The hospital • We observed there was effective handovers at shift reported 0.6% of all incidents as resulting in severe changes, to ensure staff could manage risks to patients. harm or death. The remaining incidents were reported We heard at handover how two patients with the same as resulting no harm, low harm or moderate harm. The surname were highlighted as a potential risk, and what information was not broken down to children or adults. action was taken to mitigate this risk. • For the same time period (April 2015 and March 2016) • There were plans and procedures in place to respond to the assessed rates of clinical incidents (per 100 bed emergencies. Staff regularly undertook scenario training days) in surgery, were similar or lower than other in emergency situations meaning their skills and independent acute providers that the provider held data knowledge were up to date. for. • Staff completed a paper clinical incident form, which Incidents they submitted to the appropriate ward or theatre • Never Events are serious incidents that are wholly manager. Managers then entered data from the form preventable as guidance or safety recommendations onto the computer system. Staff could all describe the that provide strong systemic protective barriers are process for reporting incidents, and gave examples of available at a national level and should have been times they had done this. All staff we spoke to had implemented by all healthcare providers. confidence in the incident reporting process. • The never event was a retained swab after gynaecology • Heads of departments investigated incidents with surgery. We saw there was a full root cause analysis oversight and support from the Quality and Risk (RCA) undertaken which did not demonstrate a cause Manager. We saw clinical incidents were a standard for the event. Staff described the investigation to us and agenda item at the Hospital Clinical Governance it was obvious the event had caused staff concern and Committee, Hospital Health and Safety Committee, worry. Staff told us how they had been supported MAC, and Head of Departments meetings. Staff told us throughout the process by the management team, and the relevant ward or theatre manager fed back to the that blame had not been apportioned. Learning from team with learning from incidents at monthly ward or the incident and implementing changes to prevent a theatre team meetings. Learning was also shared via recurrence was limited as the cause was not identified. hospital bulletins. We saw copies of the theatre team We saw from copies of theatre departmental meetings meeting minutes, which showed feedback and lessons that the never event had been discussed. learned from incidents were discussed. • The hospital reported one unexpected death between • Staff we spoke with were aware of the duty of candour April 2015 and March 2016. We reviewed the patient’s under the Health and Social Care Act (Regulated notes and the RCA and found staff recognised and Activities Regulations) 2014. The duty of candour is a responded appropriately to the deteriorating health of regulatory duty that relates to openness and the patient. We saw meeting minutes from the medical transparency and requires providers of health and social care services to notify patients (or other relevant persons) of “certain notifiable safety incidents” and provide them with reasonable support. Staff knew what

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duty of candour meant and could describe their • The hospital reported three surgical site infections responsibilities relating to it and gave examples. We also (SSI’s) in the same time period. We saw that RCA reviewed a sample of clinical incidents, patient notes investigations were undertaken for these three and RCA’s and saw evidence that staff had applied duty incidents. They were discussed at infection prevention of candour appropriately. For example when a patient and control (IPC) meetings and findings were shared suffered a complication after surgery it was with staff via departmental meetings. documented throughout the patient’s notes • We saw copies of the BMI Healthcare group’s hand conversations with the patient’s next of kin. hygiene policy, standard infection control precautions • The hospital did not carry out mortality and morbidity policy, antibiotic guidelines and clinical uniform policy. review meetings as a matter of course. This was in part All these policies were in-date and referred to national due to the relatively low number of patients treated and guidelines, for example the World Health Organization the consequent low numbers of patients that would fall (WHO) Guidelines on Hand Hygiene in Health Care into these categories. We saw that all deaths that had (2010). These policies were readily available to staff on occurred were discussed and reviewed at the Hospital the hospital’s intranet and in resource folders. Infection Clinical Governance Committee, Hospital Health and prevention and control was included in the mandatory Safety Committee, MAC, and Head of Departments training programme. meetings. • We saw staff complying with infection prevention and control policies. For example, we saw nine members of Safety thermometer or equivalent (how does the staff wash their hands and 12 member of staff use service monitor safety and use results) alcohol gel hand sanitiser in accordance with the WHO • The safety thermometer is a national tool used for “five moments for hand hygiene”. We saw hand sanitiser measuring, monitoring and analysing common causes bottles readily available throughout clinical areas in of harm to hospital inpatients. These include falls, new theatres and on the wards. pressure ulcers, catheter and urinary tract infections • All members of staff we saw in clinical areas were bare (UTIs) and venous thromboembolism (VTE) (blood clots below the elbows to prevent the spread of infections in in veins). accordance with the BMI Healthcare clinical uniform • Between April 2015 and March 2016 the hospital policy and national guidance. reported no incidents of VTE or pulmonary embolism. • We saw there was an infection control and prevention • In the same time period the hospital reported no lead for the hospital; they were supported by pressure ulcers or UTIs for catheterised inpatients. departmental link practitioners. There was a monthly • We saw that safety thermometer data was displayed in link IPC meeting led by the IPC lead. The meeting both ward areas. minutes demonstrated audit findings were reviewed and current topics relating to IPC were discussed. For Cleanliness, infection control and hygiene example it was identified that bed mattresses were • The hospital reported no infections of MRSA, being stored on the floor when not in use, this was Clostridium difficile or methicillin sensitive discussed and an action plan had been agreed. Staphylococcus aureus between April 2015 and March • The Hospital Infection Prevention and Control 2016. Committee met quarterly and was chaired by the • We spoke to a pre-assessment nurse, who told us the Director of Clinical Services. We saw copies of meeting hospital swabbed patients at risk of carrying MRSA, for minutes which demonstrated a variety of IPC topics example all NHS patients and patients who have were discussed, for example Public Health England previously had MRSA, at the pre-assessment clinic. audit requirements and the RCA of an E-Coli infection. In Patients who had a telephone pre-assessment were addition there was a BMI Healthcare Group lead IPC made an appointment to come to the outpatient meeting every three months; this discussed any themes department to be swabbed. relating to IPC issues across the BMI Healthcare Group. • The hospital reported three incidents of Escherichia coli • We saw there was an infection prevention audit report (E-Coli) in the same time period; we saw that a full RCA and action plan for 2016 and this was discussed at IPC had been completed for each infection. meetings.

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• Equipment was marked with a sticker when it had been • Patient-led assessments of the care environment cleaned and ready for use and areas we saw were visibly (PLACE) are a system for assessing the quality of the clean. patient environment; local people go into hospitals as • Disinfection wipes were readily available for cleaning part of teams to assess how the environment supports a hard surfaces and equipment surfaces in between patient’s privacy and dignity, food, cleanliness and patients, and we witnessed staff using these. general building maintenance. • Waste in all clinical areas was separated and in different • In the PLACE audit 2015 BMI Runnymede Hospital coloured bags to identify the different categories of scored 99% in relation to cleanliness which is better waste. This was in accordance with HTM 07-01, control than the national average of 98%. In relation to general of substance hazardous to health and Health and Safety building maintenance of the hospital BMI Runnymede at work regulations. Hospital scored 93% which is better than the national • Domestic staff were employed by BMI Healthcare, we average of 92%. spoke to two members of domestic staff both of whom • Hand hygiene audits in March 2016 showed 64% had worked at the hospital for a number of years and compliance in theatres and 90% compliance on the enjoyed their work. wards, this is worse than the hospital target of 100%. • We saw there was a variety of daily, weekly and monthly • We saw a company representative was not permitted cleaning schedules; these were fully completed. into theatres during our inspection because they were • The domestic supervisor conducted regular audits to wearing false nails and jewellery which was against the ensure the compliance to the cleaning schedules. provider’s clinical uniform policy. • A member of theatre staff told us “high standards of However: patient care starts with a clean environment”. We saw staff cleaning the theatres prior to the start of the • We observed an operation in theatres where staff placed operating session. surgical instruments outside of the laminar flow (clear • Decontamination and sterilisation of instruments was air) area. This may have compromised sterility and managed in a dedicated facility offsite, the facility was increased the risk of infection to the patient. responsible for cleaning and sterilising all re-usable • We observed staff wearing theatre ‘scrubs’ outside of instruments and equipment used in the operating the theatre environment. This is against the Association theatres, ward and clinics. for Perioperative Practice (AfPP) 2011 publication which • The clinical waste unit was secure and all clinical waste stated “theatre attire should not be worn outside the bins we checked were locked. clinical area or public areas.” • We observed that sharps management complied with • We asked the theatre manager if staff were allowed to Health and Safety (Sharp Instruments in Healthcare) wear ’scrubs’ outside of the theatre environment, they Regulations 2013. We checked 20 sharp bin containers stated it was permitted, but staff were not allowed to and all were clearly labelled to ensure appropriate wear them whilst eating in the canteen. We reviewed the disposal and traceability. BMI Healthcare group’s clinical uniform policy which • We saw posters displayed which outlined what action stated “Ideally staff should change into outdoor clothing must be taken if a member of staff sustained a sharp before leaving the theatre environment.” injury; this information was also in departmental Environment and equipment resource folders. • We noticed that sharp safe cannulas (a thin tube • We checked 29 items on the adult emergency trolley inserted into a vein) and sharp safe hypodermic needles and 40 items on the paediatric trolley in theatres and all (hollow needle) were being used. These devices were in date. We checked the emergency trolleys on reduced the risk of a member of staff receiving a sharps both wards and all items were in date and ready for use. injury. • We saw in theatres and the wards staff had fully • All taps and showers were tested twice weekly and run completed the trolley checklist throughout June and for two minutes at their maximum velocity. This was July 2016 to provide evidence they had checked done to prevent legionella bacteria developing. emergency equipment. We saw on the staff allocation

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board the member of staff responsible for checking the • We saw that there was an adequate number of portable emergency trolley was highlighted by an asterisk. In oxygen cylinders; we checked 16 cylinders which were in theatres it was part of the daily check list to complete date and labelled. the emergency trolley. • Theatres were fitted with an uninterrupted power • In theatres, we checked the anaesthetic machine supply (UPS) which meant lifesaving equipment would logbooks for the anaesthetic machines. We saw staff continue to operate in the event of a power cut. had fully completed both logbooks with evidence of • There was a hospital generator that was tested monthly; daily pre-use checks in accordance with the Association this ensures there was a backup supply of electricity if of Anaesthetists of Great Britain and Ireland (AAGBI) the main electricity supply failed. guidelines. This provided assurance that the anaesthetic • The staff we spoke with confirmed they had access to machines worked safely. the equipment they required to meet peoples’ care • In the theatre recovery area, we checked 12 items on the needs. difficult airway trolley. All 12 items were in-date. We saw • We saw there was a full range of paediatric equipment there was a checklist to provide assurance of regular available; however there was only one defibrillator in safety checks. The AAGBI guidelines, “checking theatres. Staff explained that a porter would bring anaesthetic equipment” (2012) stated, “equipment for another defibrillator to the cardiac arrest as standard the management of the anticipated or unexpected procedure. This meant the hospital had put a process in difficult airway must be available and checked place to mitigate the risk. We saw it was clearly labelled regularly”. Staff told us that the trolley's contents and on the paediatric emergency trolley that this was the layout had been designed to mimic the trolley that process. anaesthetists are familiar with in the NHS hospital. • Theatres used a smoke extraction system for all major • In theatres we observed staff checked all surgical surgical cases, in accordance with Health and Safety instruments and gauze swabs before, during and at the Executive Evidence which prevents exposure and end of patients’ operations. This was in line with the harmful effects of diathermy plumes (surgical smoke) to Association for Perioperative Practice (AfPP) guidelines. staff (RR922) (2012) guidelines. • We saw that portable appliance testing (PAT) labels • We saw Health and Safety Control of Substances were attached to electrical items showing that it had Hazardous to Health substances were stored in line with been inspected and was safe to use, however on some Health and Safety Executive guideline SR24. equipment it was difficult to locate the relevant sticker • There were two collections and deliveries of as there was more than one sticker type. We checked 45 instruments a day in theatres and an instrumentation electrical items and we could not find evidence of an coordinator who ensured relevant equipment was electrical safety check on nine pieces of equipment. available. • We checked 50 consumable items and five items • We saw there was a corporate five year equipment (gloves) had expired. replacement programme .There were medical device • The hospital had an outside medical gas cylinder leads in each department who had additional storage which was compliant with: The Department of responsibilities. For example the lead in theatre was in Health ( DOH) The Health Technical Memorandum the process of compiling an accurate equipment (HTM) 02-01 Part A guideline stated medical gas database which evidenced when equipment was last cylinders should be kept in a purpose built cylinder serviced. store that should allow the cylinders to be kept dry, • Staff told us that Runnymede hospital employed clean condition and secure enough to prevent theft and engineers who repaired and maintained some misuse. equipment but the majority of medical equipment was • We inspected the gas manifold room that housed the serviced and maintained by an external contractor. piped medical gas supply. The room was located at the back of the building. Appropriate signage was in place Medicines to notify people what was contained within. The room itself was locked and this prevented any potential sabotage to the supply of medical gases.

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• The hospital did not have their own pharmacy on site, This was in line with guidance from NHS Protect which they had a service level agreement (SLA) with the local stated, “Prescribers should keep a record of the serial NHS hospital, which supplied all medications and numbers of prescription forms issued to them. The first advised regarding pharmacy matters. and last serial numbers of pads should be recorded”. • We saw on the wards medicines were stored safely and • Staff told us that if they needed advice regarding a securely in line with relevant legislation for the safe medication they would either ring the pharmacy storage of medicines. department at the NHS hospital or they would access • We checked the controlled drugs (CD) cupboard on both the British National Formulary (BNF). We saw paper wards. Controlled drugs are medicines liable for misuse copies of BNF’s contact details and instructions on how that required special management. We saw the CD to access it on line. cupboard was locked, and only authorised staff with a However: key could access CDs. We checked the stock levels of two CDs. We saw the correct quantities in stock • We checked the CD book in theatre one, there were according to the stock list, and that all were in-date. multiple occasions when only one signature was • We checked temperature monitoring charts for the drug recorded, and instead of another signature ‘surgery’ had fridges in anaesthetic room one, theatre two and been written. We asked staff about this and they recovery. The records showed staff had monitored the explained this occurred when CD’s were given to the temperature of both fridges daily in the last month. This surgeon for use during surgery; however, the surgeon provided assurances the theatre team stored had not signed to confirm administration of the drug. refrigerated drugs within the correct temperature range This was against hospital policy and Misuse of Drugs to maintain their function and safety. Regulations 2001 and Safer Management of Controlled • We saw the temperature of the drugs fridge on Drugs: a guide to good practice in secondary care Wentworth ward was within the expected range. We (England). asked two members of staff, and both knew the safe • We checked the CD book in theatre two and recovery; temperature ranges for the fridge and at what we saw incomplete records of the CD’s. This was temperatures they should take action. because staff blanket-signed for the drugs rather than • We saw the temperature monitoring checklist showed signing individually at each stage of the dispensary staff had recorded the fridge temperature. There was a process. However, the daily checking process of CDs in checklist for monitoring the ambient temperature of the theatres was otherwise robust. medicines storage room. This was to ensure that drugs • We saw in theatres that there was a mixture of two stored at room temperature remained within the different batch numbers in a box; this was against the manufacturer’s indicated temperature range. BMI Healthcare Safe Management of Medicines policy • We reviewed nine prescription charts and found them to which stated “the transfer of medicines from one be legible and completed appropriately. Patient container to another will not occur.” allergies had been clearly noted on the chart and on • Staff told us that some surgeons used a mixture their identity band which alerted staff to their allergy. containing local anaesthetics and other pain killers. The nine charts we reviewed demonstrated that These mixed together in a sterile jug for injection at the prescribing was in line with national guidance and that end of hip and knee replacements. As a result of this all were compliant with the National Institute for Health practice patients were given medicines outside the and Care Excellence (NICE) VTE guidance. A section in terms of their licence. BMI had a policy and system to the front of this chart confirmed a completed VTE gain approval for medicines used outside the terms of assessment had taken place and that prophylaxis had their licence (BMI Healthcare Unlicensed Medicines, been prescribed and administered. Staff recorded Medicines Out of Licence Policy) which we saw. We patient allergies on the patient’s prescription chart. asked the provider to supply us with documents • On Wentworth ward, there were accurate records of the required by their policy supporting the use of this drug quantity of private prescriptions in stock. This reduced mixture but were not supplied with these. The policy the risk for blank prescriptions to go missing un-noticed. required a register of approved and risk assessed

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unlicensed medicines and the use of medicines outside • A nurse in pre assessment showed a pre assessment of their product licence to be maintained. We requested, questionnaire; this was a paper based assessment but were not supplied, with a copy of this register which completed by the patient to determine their suitability contained this drug mixture. for their recommended procedure. • The policy also required prescribers to ensure patients • We saw there was a variety of risk assessments used, for were provided with accurate and clear information that example infection control risk assessments and patient meets their needs, including information on side effects pressure area assessments. when medicines were used outside of their licence. We Safeguarding did not see any evidence that supported compliance with this aspect of the policy. This meant the hospital • There was a BMI Healthcare Group Safeguarding were not compliant with their own policy. Children policy and a Safeguarding Adults policy. • Mixing of medicines in this way was recognised by the • The Director of Clinical Services was safeguarding lead BMI policy as increasing the risk of infection. The for children and adults but supported on children by the National Patient Safety Alert (NPSA) NHS/PSA/W/2015/ Children’s Services Clinical Lead. 005 Stage One: Warning Risk of death or severe harm • One hundred percent of theatre and pre-admission staff due to inadvertent injection of skin preparation solution had completed either level one or level two reinforces the alert that was issued in England in 2007. safeguarding vulnerable adults and safeguarding This alert stipulated that injections must be drawn up children training. This was better than the BMI from the source bottle or ampoule directly into syringes Healthcare target of 90%. that are labelled and checked prior to administration • One hundred percent of ward staff had completed either and that ‘open systems’ should never be used to contain level one or level two safeguarding children training. medication prior to injection. The process staff This was better than the BMI Healthcare target of 90%. described in the preparation of this mixture did not One hundred percent of ward staff had completed level comply with this guidance. This meant patients were at two safeguarding vulnerable adults training and 96.3% increased risk of infection. of ward staff had completed level one safeguarding vulnerable adults training. This was better than the BMI Records Healthcare target of 90%.The level of training • We saw there was BMI Healthcare Group Policy for the undertaken was dependent on the staff member’s job retention of records which was in date. role and level of exposure to adults and children. • Staff adhered to this policy, for example, staff stored • Posters displayed ‘What to do if you’re worried about an notes securely in the nurses’ office to prevent adult’s welfare’; these showed flowcharts on action to unauthorised access to confidential patient data. be taken and included contact details of who could be • Patients’ records were kept on site, during our contacted for advice. This served to remind staff of the inspection we requested several patients’ records and correct reporting processes. these were obtained quickly. • The Director of Clinical Services is the hospital’s adult • We examined 11 sets of patients’ records; there was a and children safeguarding lead and had overall good standard of documentation in all areas. For responsibility for safeguarding within the hospital. example, patients had care plans which identified all • Staff we spoke with could identify the safeguarding their care needs which were fully completed. leads and described how to report safeguarding • We saw some patients followed standardised pathways, concerns. such as a total hip replacement pathway. This was • All consultant surgeons and anaesthetists who treat personalised through individual risk assessments and children and young people had undergone level three notes made in the care plans. We saw thorough safeguarding training as part of their mandatory training evidence of pre-assessment in all three sets of notes. in their NHS hospital. • We saw there was a BMI Healthcare nursing • All contracted paediatric nurses were trained to pre-operative assessment policy which referenced good safeguarding level three. Paediatric nurses who were practice guidance from NICE (National Institute for supplied by an external agency were also level three Health and Clinical Excellence). trained.

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Mandatory training Transfer of Critically ill Patients. We also saw the BMI Healthcare group policy used by the hospital for the • Overall mandatory training rates for theatre staff was emergency transfer of patients to specialist units 95.2% and for pre- admission staff was 98.7%; both rates outside of BMI Healthcare. were better than the BMI Healthcare target of • There was a transfer agreement with the local NHS 90%.Overall mandatory training rates for ward staff was hospital for the transfer of children if required. The NHS 89.1% which was worse than the BMI Healthcare target hospital could be accessed by an adjoining corridor of 90%. from BMI Runnymede. There was also an agreement • There were 15 mandatory training courses for surgical with the Children's Acute Transfer Service (CATS) for staff. This was a combination of online and emergency retrieval of critically ill children if required. classroom-based training. Staff completed the appropriate number and type of courses from this list • The theatre manager described instances to us when he relevant to their role. This was monitored through the felt it was not safe with the staffing levels to accept staff member’s appraisals and in addition managers patients who required emergency surgery and were received notification when a staff member’s mandatory therefore transferred to the local NHS hospital. training had lapsed. • Pre- assessment of patients was undertaken either by Assessing and responding to patient risk telephone or face-to-face by a pre- assessment nurse. The nurse had access to anaesthetists should they have • The hospital used the National Early Warning System any concerns or questions. (NEWS) track and trigger flow charts. NEWS was a simple scoring system of physiological measurements (for • Pre-assessment of patients for surgery included a example blood pressure and pulse) for patient thorough assessment of risk. We reviewed two sets of monitoring. This enabled staff to identify deteriorating patient notes on Burwood ward, and saw evidence of patients and provide them with additional support. We falls risk assessment, dementia screening, infection reviewed four patients’ NEWS charts. Staff had prevention and control risk assessment, risk assessment completed all four accurately and fully. We saw evidence for pressure ulcers and assessment of nutritional status. of increased monitoring and intervention when These assessments were vital to assess a patient’s clinically indicated in line with national guidance. suitability for surgery and to enable staff to make any necessary adjustments to ensure safe care. For example, • An audit undertaken by the hospital in March 2016 staff allocated patients with a physical disability to a showed that out of 20 patients 73% of all patients were bedroom with a walk-in shower. being monitored on NEWS and 73% of patients were • Children attending for surgery were risk assessed by accurately scored and had evidence of appropriate and registered children’s nurses, either face to face or on the timely intervention. This meant that 27% of patients telephone, before admission. A surgery date was only were at risk of deteriorating because of a lack of scheduled once the paediatric team had confirmed a monitoring using NEWS. child’s suitability for surgery. • A Paediatric Early Warning System (PEWS) was used to identify deteriorating patients. We saw observations • Nursing staff told us medical support was readily were recorded and calculated accurately in all three sets available when required as the Resident Medical Officer of paediatric care records we reviewed. (RMO) attended to patients quickly. We witnessed a nurse bleeping the RMO for advice regarding a patient • The hospital had a service-level agreement with a local who they were concerned about, they responded NHS hospital which was attached to Runnymede quickly and gave advice. hospital. This enabled them to transfer any patients who became unwell after surgery and needed critical care • The hospital’s RMOs provided medical cover 24 hours a support. We saw evidence of agreed Standards for the day, seven days a week. This ensured nurses could

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always quickly escalate any issues concerning a five steps to safer surgery. These are team briefing, sign deteriorating patient. The RMO also informed the in (before anaesthesia), time out (before surgery starts), patient’s consultant in an emergency so that they could sign out (before any member of staff left the theatre).We provide consultant-level care. saw staff fully completed all the required checks. • A RMO told us that there was a robust support process • We reviewed ten completed WHO checklists; of these in place should they require support or advice quickly ten, one was missing the signature of the staff member initially via telephone and consultants would attend the who carried out the sign out element, one was missing a hospital if needed. signature of the recovery practitioner and two were missing the signature of the consultant surgeon. This • We saw all patients had a VTE assessment completed meant there was no assurance that the safety checks and all patients wore anti-embolic stockings. We saw had been completed. Staff told us the practice of the completed neurovascular assessments and pressure surgeon signing the checklist was still being embedded. area assessments were completed. • We observed staff using specific WHO checklists for • A recent report on patient transfers to the local NHS different procedures, for example for eye surgery. This hospital showed the hospital had transferred six surgical ensured staff checked the most important safety factors patients to the local NHS hospital between April 2015 relating to a specific procedure. and March 2016. • We saw that as a result of a National Patient Safety Alert: • We reviewed a sample of the patients’ notes relating to NHS/PSA/W/2015/005 Risk of death or severe harm due the unplanned transfers and given the nature and to inadvertent injection of skin preparation solution, the volume of operation undertaken, all were appropriate antiseptic skin preparation had been changed. The and there were no common themes or concerns. hospital was now using pre filled chlorohexidine devices, which minimised the risk of inadvertent • There were five unplanned returns to the operating injection of skin preparation solution. theatre for the period April 2015 – March 2016. We undertook a review of a sample of these unplanned Nursing staffing returns and all had been treated appropriately. • The theatre department had 20.5 whole time equivalent • Ward nurses staff told us they checked the pregnancy (WTE) staff; of these 5.8 WTE were operating department status of female patients of potential childbearing age practitioners (ODP’s) and Health Care Assistants (HCA’s) on the morning of planned surgery by asking them for and the remaining 14.7 WTE were qualified nurses. the date of their last menstrual period (LMP). We saw a • The theatre department had the full establishment of space on the hospital’s pre-operation checklist to record care assistants, nurses and operating department this. However, guidance from the National Patient Safety practitioners, with no staff vacancies in these areas. Agency in their 2010 Rapid Response Report: Checking • On the day of our visit, we saw staffing levels met the pregnancy before surgery highlights “the unreliability of AfPP guidelines on staffing for patients in the LMP as a sole indicator for potential for pregnancy”. Staff perioperative setting. The guidelines suggested a told us they did not routinely perform a urine test for minimum of two scrub practitioners, one circulating pregnancy on all female patients before surgery. staff member, one anaesthetic assistant practitioner • The hospital consistently met their NHS contracted 95% and one recovery practitioner for each operating list. target screening rate for VTE risk assessment between • However, theatre staff told us staffing levels in theatres April 2015 and March 2016. sometimes fell below AfPP guidelines, this usually occurred when there was a significant number of staff • We observed theatre staff carrying out the WHO Surgical on sick leave or annual leave. We asked the theatre Safety Checklist for six procedures. The WHO checklist is manager how often staffing fell below AfPP guidelines; a national core set of safety checks for use in any they did not have the information available. operating theatre environment. The checklist consists of

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• The theatre manager risk assessed all operating lists physiotherapy requirements and any safety issues. For where this happened and told us if the outcome of risk example at the handover we attended it was highlighted assessment indicated it was unsafe to continue, that there were two patients on the ward with the same managers would cancel the operating list. surname, the patients had been placed at opposite • There was low use of bank and agency theatre nurses, sides of the ward to try and reduce any risk. ODP’s and HCA’s between April 2015 and March 2016, • The hospital used the BMI staff planning tool. The when compared to other independent acute hospitals planning tool calculated the nursing hours and skill mix that the provider benchmarked against. The highest needed for the planned patient numbers and acuity (20%) use of theatre agency or bank staff was in October levels. The hospital told us they used the tool to plan the 2015 and was for ODP’s or HCA’s. The lowest (0%) use of appropriate number of hours and skill mix needed to theatre agency or bank staff was for three months meet demand five days in advance, with continuous during the same time period and was for ODP’s and review on a daily basis. The hospital told us they also HCA’s. entered the actual hours staff worked retrospectively to • The two surgical wards had 24.9 WTE staff; of these 8.8 understand any variances from the planned hours and WTE were HCA’s and the remaining 16.1 WTE were the reasons for these. nurses. • The Royal College of Nursing (RCN) recommends a nurse • There were two WTE posts vacant for inpatient nurses to patient ratio of 1:8 (RCN 2012). This meant one giving a vacancy rate of 11%. This rate was higher than registered nurse (RN) for eight patients; surgical services other independent acute hospitals that the provider were compliant with this. We saw on the ward the nurse benchmarked against. Hospital managers told us that to patient ratios varied between 1:5 and 1:6, this was whilst recruitment had significantly improved, above the RCN recommendations. Runnymede hospital was located in a very competitive • The hospital told us there was a nominated manager on area for staffing which made recruitment of new team call each day, we saw this displayed in the reception members difficult. area of the hospital. During the night, the hospital had • There was variable use of bank and agency staff for an on-call senior nurse rota to ensure the same level of inpatient nurses between April 2015 and March 2016, service and to accept out of hours admissions. however, they were generally higher when compared to • We saw that the daily actual versus planned staffing other independent acute hospitals that the provider levels were displayed on the ‘ward boards.’ benchmarked against. The highest (26%) rate of bank Surgical staffing and agency staff use for inpatient nurses was in July 2015 and the lowest (12%) was in February 2016. • There were 168 consultants who had practising • There was low use of bank and agency staff for inpatient privileges at the hospital; 48% had not undertaken work health care assistants when compared to other at the hospital between April 2015 and March 2016. independent acute hospitals that the provider Practising privileges is a term which means consultants benchmarked against. have been granted the right to practise in an • There were two registered children’s nurses who worked independent hospital. on the wards, theatre and recovery. The children’s lead • Eighteen consultants had their practicing privileges nurse told us that they worked between two sites; at the removed in the same time period, the most common BMI Runnymede and another local BMI hospital reason being due to retirement. approximately 12 miles apart in distance. The children’s • Twenty five consultants had their practicing privileges lead nurse had been in post for 19 months and the suspended during the same time period, the most registered children’s nurse had been in post for three common reason (44%) were suspended due to months non-compliance with paperwork but were reinstated • There were three daily nursing handovers, one at the when this was received. beginning of the day, one at lunchtime and the other • The hospital used an international agency to provide towards the end of the day. We attended a handover 24-hour, seven days a week Resident Medical Officer which was informative and included management plans for patients, upcoming consultant reviews,

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(RMO) cover on a rotational basis. This ensured a doctor • The hospital also had emergency policy including any was on-site at all times of the day and night should an major incidents occurring at the NHS hospital attached emergency arise. The RMO we spoke with worked a shift to Runnymede Hospital. pattern of two weeks on followed by two weeks off. • We saw a paper copy of each policy was within a • The RMO conducted regular ward rounds to ensure resource folder in each ward and department ensuring patients were safe. We saw the RMO providing medical easy access to all staff in needed. cover on Burwood Ward. The RMO reported any • The hospital had a back-up generator to ensure services changes in a patient’s condition to their consultant and could continue in the event of a disruption to the main followed the consultant’s advice regarding further power supply. Maintenance staff told us the generator treatment. was checked on a monthly basis, generator testing • The RMO told us the consultants were approachable, provided the hospital with assurance that the generator reacted quickly in emergencies and were easily would provide back-up power and enable services to contactable. The nurses and the RMO told us that continue in the event of a power failure. consultant lead care was available out of hours and at weekends. Are surgery services effective? • All consultant surgeons, as a requirement of their practising privileges, were required to be available and Good ––– remain within a thirty minute radius of the hospital for the duration of their patient stay or to arrange suitable cover with another consultant surgeon from the same We rated effective as good because: specialty. The consultants had direct access to the ward • Patients’ care and treatment was planned and delivered by telephone. Surgeons were expected to visit their in line with current evidence-based guidance, patients daily until the patient has met their discharge standards, best practice and legislation. This was criteria or to arrange cover. monitored and benchmarked to ensure consistency of • The anaesthetist was also required to be available for practice. the duration of the patient's stay in hospital. This • Patients had comprehensive assessments of their needs ensured availability of anaesthetic cover should a return and their care and treatment was regularly reviewed to surgery become necessary or if advice was required and updated. regarding pain relief. Staff told us anaesthetists were • The hospital participated in relevant local and national contactable and approachable when needed. audits and contributed to national data to monitor • Staff told us RMOs carried out a formal handover. performance such as the national joint registry. However, we did not see this as there was no change • Staff were qualified and had the skills they needed to over during our visit. carry out their roles effectively and in line with best Major incident awareness and training practice. Staff were also supported to maintain and further develop their professional skills and experience; • The hospital provided scenario-based training exercises we saw staff in theatres were undergoing training to which included five paediatric and five adult become first assistants. resuscitation exercises a year. In addition we heard • Staff obtained and recorded consent in line with within the last 12 months a simulation fire evacuation relevant guidance and legislation. exercise was undertaken in theatres. • We saw the hospital’s business continuity policy. The Evidence-based care and treatment policy was in-date and produced with reference to the • We observed how patient care and treatment reflected NHS England Core Standards for Emergency current legislation and nationally recognised Preparedness, Resilience and Response (May 2015) and evidence-based guidance. Policies and guidelines were ISO 22301 Business Continuity Management Systems developed in line with the Royal College of Surgeons Requirements. The policy set out clear roles and and the National Institute for Health and Care responsibilities to ensure service continuity in the event Excellence (NICE) guidelines. of a business continuity incident.

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• In theatres, and in the patient notes, we saw evidence of • The hospital provided data to the National Joint the hospital providing surgery in line local policies and Registry (NJR). The NJR collected information on all hip, national guidelines such as NICE guideline CG74: knee, ankle, elbow and shoulder replacement Surgical site infections: prevention and treatment. For operations to monitor the performance of joint example, in theatre we saw that the patient’s skin was replacement implants. prepared at the surgical site immediately before incision • The hospital told us they had positive relationships with using an antiseptic (aqueous or alcohol-based) the local NHS Trust and Clinical Commissioning Group ( preparation: povidone-iodine or chlorhexidine. CCG) and were fully committed to driving improvement • In theatres we saw a patient’s temperature was through the Standard Acute Contract and measured and documented before induction of Commissioning for Quality and Innovation (CQUIN’s) on anaesthesia and then every 30 minutes until the end of an annually basis, these were reviewed and updated surgery. This adheres to: Hypothermia: prevention and quarterly. management in adults having surgery NICE guidelines Pain relief [CG65]. • We reviewed four patient records which all showed • The pre assessment lead told us that patients were evidence of regular observations, for example, blood counselled on pain management and that the pressure and oxygen saturation, to monitor the patient’s anaesthetist would discuss pain relief methods prior to health post-surgery. Staff had completed all four surgery. observation charts in line with NICE guideline CG50: • The recovery staff told us that some staff had Acutely ill patients in hospital- recognising and undertaken specialist study days in order to have a responding to deterioration. better knowledge of pain management, and they acted • There were specialist clinical pathways and protocols as a resource for other staff. for the care of patients undergoing different surgical • There was no dedicated pain team at the hospital. procedures. For example the hip and knee replacement However, consultant anaesthetists with an interest in pathway, these were designed to specifically assess risks pain relief gave advice on pain management. associated with these procedures. This demonstrated • We spoke to two patients who had recently undergone best practice and adherence to NICE guidelines. surgery. Both told us their pain was well controlled and • The hospital was meant to perform World Health said nurses responded quickly when they requested Organization (WHO) checklist audits. This included one additional pain relief. observational audit and one documentation audit a • Nurses on Burwood ward asked patients whether they week, measuring 18 different indicators. The purpose of had any pain as part of their hourly ward rounds. We this is to check staff compliance with the WHO Surgical reviewed four sets of patient notes, which showed Safety Checklist. However, the theatre manager evidence of pain assessment as part of hourly ward responsible for undertaking these audits told us they rounds. were not consistently undertaken. We asked the theatre • We saw potent pain relief was prescribed for the manager why they were not undertaken and they said it immediate post-operative period when the patient was was due to a lack of prioritisation. This meant there in recovery. This meant if a patient woke up from the were not adequate assurances that the WHO checklist anaesthetic and experienced pain it could be was undertaken consistently and in line with national administered to the patient quickly rather than it having guidance. to be prescribed. • The hospital provided data which demonstrated • We observed pain relief administration in recovery non-compliance with the WHO audit between July 2015 which included a reassessment of pain to monitor if the and December 2015. This meant the hospital could not pain relief had been effective. be assured staff were performing the WHO checklist in a • We saw the use of a pain assessment tool and analgesia standardised and safe manner. ladder in four sets of patient notes we reviewed. Staff

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asked patients to rate their pain between one and 10, • The menu followed a four week rotation, however if a one meaning no pain and 10 being extreme pain. The patient was admitted for longer than four days they analgesia ladder set out guidelines for the management could have a home comfort diet. The home comfort diet of pain. offered additional food options. • We observed pain assessment tools used for children to • The external contractor had a dietician who could be communicate pain thresholds. Staff recorded pain contacted for support and advice. scores in patients’ care records; all care records we • There was a nutritional breakdown of each meal which looked at showed pain scores with management plans if meant staff and patients knew exactly the content and the patient was in pain. Children selected the tool they nutritional value of each meal. wished to use to communicate pain thresholds, for • Puree and mashed food diets were available on request example, a child could point at a scale line from 0-10, and specialist high calorie drinks were also available if ten being the most painful, or they could use ‘smiley needed. faces’, where the child chose a face that best described • We reviewed patient menus and saw a balanced variety their own pain level. of choices. This included options for vegetarians. • Patients told us nurses offered them drinks as part of Nutrition and hydration their hourly ward rounds. We also saw patients had • The hospital used the Malnutrition Universal Screening access to a water jug at their bedside to enable them to Tool (MUST) as part of pre-assessment screening. The stay hydrated. MUST tool enabled staff to identify patients at risk of • Patients generally gave us positive feedback regarding malnutrition and make adjustments to mitigate any risk the food, although some patients commented the where appropriate. We reviewed three sets of patients choice was limited if admitted for a significant time. notes, which all provided evidence of MUST assessment. • Families were welcome to bring in particular food for • All three notes also included a “dietary requirements their child, if they wanted and there was a specific record” completed as part of pre-assessment. This children’s menu. Parents were provided meals when allowed staff to identify any special dietary they accompanied their child. Parents commented that requirements, such as gluten intolerance, before there was an excellent choice of food for children and admission so they could advise the catering staff to children were encouraged to choose what they wanted prepare a suitable meal for the patient. to eat. • We reviewed the notes of a patient who was unable to • The hospital scored 89% in the 2015 Patient-led take food by mouth due to the operation undertaken assessments of the care environment (PLACE) audit for and needed nutritional support via a feeding tube. We overall food which was worse than the national average saw that a dietician from the local NHS trust had been of 93. In the same audit the hospital scored 79% for involved in the patient’s care which meant the patient organisational food which was worse than the national had specialist nutritional support. In addition we saw average of 92% and 98% for ward food which was better the dietician had given training to the patient about than the national average of 94%. their feeding tube and what action to take if they Patient outcomes experienced a problem after discharge. • An external contractor provided a range of pre-packed • There were eight cases of unplanned readmission within meals for the hospital; we spoke to the catering 28 days of discharge between April 2015 and March manager and the operations manager. They explained 2016. that they had a daily meeting to discuss specialist • The assessed rate of unplanned readmissions (per 100 dietary requirements of the patients to be admitted the day case and inpatient attendances) was not high when following day. compared to a group of independent acute hospitals • Gluten free products were readily available in the that the provider holds data for. hospital and different varieties of milk. • The hospital reported five unplanned returns to theatre between April 2015 and March 2016, three were in July 2015 and two were in October 2015.

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• We reviewed the incident forms for the unplanned • The hospital reported all registered nurses working in returns to theatre. In the majority of cases inpatient departments had validation of professional post-operative complications was the reason for further registration. surgery, although we saw there were no common • We saw competency records for a member of staff themes. In all cases, we saw evidence staff treated undergoing surgical first assistant training who was patients with post-operative complications awaiting final sign off of her paperwork. appropriately. • Several members of staff were undergoing the surgical • The hospital provided data to national Patient first assistant training. Currently first assistants were Reportable Outcomes Measures (PROMS). PROMS uses provided via a mixture of agency staff and surgeons patient questionnaires to assess the quality of care and providing their own. We asked the theatre manager if outcome measures following surgery. they held records of the first assistants, such as evidence • The hospital provided PROMS data from two areas: hip of The Disclosure and Barring Service (DBS), indemnity replacements (Oxford Hip Score), and knee insurance and evidence of training and qualification. replacements. PROMS data was only collected and The theatre manager said they did not keep DBS records submitted for NHS patients. for first assistants who accompanied surgeons but did • The provider does not have enough data available to hold records of indemnity insurance and evidence of calculate many elements of the PROMS scores. However training and qualification. Seventy eight percent of the limited data demonstrated the hospital's adjusted nurses working on the wards, 70% of health care average health gain for PROMS for Primary Knee assistants (HCA’s) on the wards and 55% of other staff Replacement was within the England average. had undergone an appraisal in 2016. This is an • The hospital told us it compared patient outcome data improvement from 2015 when 28% of inpatient nurses, with all hospitals across BMI Healthcare group using the 0% of inpatient HCA’s and 25% of other staff had an corporate clinical dashboard. BMI Healthcare also appraisal. contributed data to the Private Healthcare Information • In the theatre department only 11% of nurses and 0% of Network (PHIN) to collate outcome data across the HCA’s and operating department practitioners (ODP’s) independent sector that was comparable with the NHS. had an appraisal in 2016.This was better than 2015 when • Results on patient outcomes were compared with other 5% of nurses and 0% of HCA’s and ODP’s had an BMI healthcare hospitals within the region and across appraisal. Lack of appraisals for staff may have meant regions across BMI Healthcare through the corporate the service did not address any potential staff clinical dashboard which used data from their incident performance issues. and risk reporting database (Sentinel). This allowed the • Data supplied by the hospital stated a consultant hospital to review their data and compare this with wishing to apply for practicing privileges is required to hospitals of a similar size within BMI Healthcare. have held or hold a substantive NHS consultant post in the last five years or can demonstrate experience of Competent staff independent practice over a sustained period • We saw a comprehensive introductory check sheet in applicable to working in the independent sector, and use on the wards and in theatres to demonstrate the who can demonstrate a support network to provide safe competency of new agency staff. cover and care for the patients. A CV together with • We saw that all staff had a competency folder detailed application form was reviewed by the Executive containing evidence of continuing professional Director. An informal meeting between the Consultant development (CPD), such as certificates for study days and the Executive Director was arranged. Should the attended. These showed that staff kept their knowledge application be progressed, the Consultant forwarded all current through continuous learning. This is required to professional registration documents, references and maintain professional registration with the Health and memberships to be reviewed by the Medical Advisory Care Professions Council or the Nursing and Midwifery Committee (MAC) who meet on a quarterly basis to Council. review all new applicants, suspensions and removals.

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• For practising privileges to be granted, the applicant lead Children's Nurse and RMO to be emergency must be licensed and on the specialist General Medical paediatric life support (EPLS) trained. All children's Council (GMC) register. The applicant was asked to nurses, bleep holders, anaesthetic and recovery staff demonstrate relevant clinical experience relating to were paediatric life support (PILS) trained. practice. • There was always an RMO who is an EPLS provider • The MAC reviewed the application with respect to the on-site and the Children's Lead Nurse was also qualified credentials, qualifications, experience, competence, as an EPLS provider. judgement, professional capabilities, knowledge, • The Runnymede hospital had a service level agreement current fitness to practice, character of and confidence with the adjoined NHS hospital which provided an held on the applicant. Recommendations were emergency resuscitation team to attend any emergency. formulated and passed to the Executive Director prior to All paediatricians, consultants and anaesthetists the application being granted. responsible for children and young persons had current • If the MAC granted practicing privileges, an information paediatric resuscitation training, depending on their pack was sent to the consultant including an offer letter category of work. to be signed accepting the terms, conditions and • Anaesthetists and paediatricians were required to hold policies. An orientation was offered to meet with advanced level of paediatric resuscitation training. relevant heads of departments. Multidisciplinary working (in relation to this core • Periodically, the hospital reviewed consultants’ service only) performance to ensure they are compliant with and have provided documentation in line with the practising • We saw copies of the pre-assessment questionnaire privileges' policy using the Consultant Database (CRDB). patients completed before coming to pre-assessment Written reminders were sent prior to expiry as clinic. This questionnaire had recently been re-designed reminders. We saw examples where failure to provide up by the lead pre assessment nurse, with input from other to date documentation resulted in suspension and disciplines in order to plan admission and discharge ultimately withdrawal of practising privileges. cohesively. We saw this included care planning with • The hospital provided data which demonstrated that 22 input from the multidisciplinary team. doctors had their practising privileges suspended in the • It included how appropriate the patient’s previous 12 months because of non-compliance with accommodation was in regards to their discharge paperwork. needs, for example did it have stairs. This information • The agency provided Resident Medical Officers (RMO’s) meant resources required for discharge could be with up-to-date advanced life support training (ALS). We obtained in advance. spoke to an RMO who confirmed they had ALS training • The hospital liaised with district nurses to arrange every four years. This was in line with current guidance ongoing care for patients post-discharge where from the Resuscitation Council (UK). appropriate. For example we saw in one patient’s notes • In addition RMO’s were required to undertake the BMI information regarding feeding requirements had been Healthcare RMO induction programme. faxed to the district nurse. • The hospital had verification of registration status for • We observed a nurse on Burwood ward discharge a 100% doctors and dentists working under practicing patient. We saw the nurse give the patient a discharge privileges who had worked at the hospital for more than pack. This included detail of ongoing care the surgery six months. team had arranged, for example, outpatient follow-up • Staff were supported to develop competencies through appointments. This allowed the patient to leave the the use of study days. For example, two theatre staff hospital fully informed about ongoing care. successfully completed the Advanced Life Support (ALS) • The multidisciplinary theatre team met bi-monthly, and course. We saw this in the June 2016 team brief notes. we saw minutes from the last two meetings. • The Runnymede hospital adhered to the BMI • Heads of departments (HOD’s) met monthly and we saw Resuscitation Policy for Children, which required the minutes from the last four meetings. • We attended a daily communication meeting “HOD huddle” this was a documented meeting which a

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representative from each department attended. It Access to information discussed a variety of issues for example, infection • We saw a resource folder in each in each department control issues, expected visitors to the hospital, which contained useful information for staff for example equipment requirements and any staffing issues. This policies and useful contact numbers. meeting meant all departments had the opportunity to • The hospital held patient notes on-site. As well as come together to discuss and resolve problems. keeping confidential patient data safe, this ensured • We saw good multidisciplinary working between timely access to information needed for patient care. We consultants, anaesthetists, nurses and ODPs and porters requested some patient notes during the inspection; within theatres. We observed effective multi-disciplinary these were found by staff efficiently and quickly. working between the RMO and nurses on Burwood • All protocols we saw were in-date, for example we ward. reviewed the BMI Healthcare document: ‘Clinical • We saw nurses on the ward undertook ward rounds with Services Policies and Procedures: Policy statement a physiotherapist on a daily basis; this provided an ‘(2015).This document set out all clinical care must be update of the patients’ progress and set future goals. underpinned by best practice and, where possible • There was a consultant paediatrician who represented evidence based practice. Its purpose is to ensure that all children and young people on the medical advisory clinical practitioners were aware of where to locate the committee who supported and advised on paediatric most up to date standard operating procedures (SOPs), matters. and policies and procedures that underpin clinical Seven-day services practice. • We saw RMO’s were also issued with a RMO clinical • Physiotherapy services were available between handbook; this contained relevant information for 8am-5pm on Saturday and Sundays, an on call example the correct format for writing medical notes physiotherapist was available after 5pm on weekdays and reporting to consultants. and weekends. • Patients were given two copies of their discharge • RMO services were provided by an agency as a 24-hour summary on discharge one copy was for the patient and seven days a week service on a rotational basis. the other copy was for the patient to take to their GP. • There was always a senior nurse available at the This meant the GP got a copy quickly, in addition the hospital as a contact point for both staff and patients, hospital also sent a copy to the patient’s GP. including help to resolve patient queries and to accept out of hours admissions. Consent, Mental Capacity Act and Deprivation of • It was a requirement of BMI Healthcare’s practising Liberty Safeguards privileges policy that consultants remain available at all • We reviewed 10 consent forms for surgery. Patients and times when they have inpatients in the hospital (both by staff had fully completed, signed and dated the phone and, if required, in person) or arrange consents to ensure they were valid. appropriate alternative named cover if they will be • The consent forms did not contain any abbreviations unavailable. that a patient may not have understood. One of the • In addition to clinical and consultant arrangements, the consent forms included percentage rates of different senior management team operated a rota for on-call complications relating to the patient’s procedure. This support out of hours. showed staff had fully informed patients of the possible • There was also an on - call rota operated by the risks and obtained informed consent. radiology should support be required out of hours, as • We reviewed three paediatric consent forms which were well as an on-call emergency theatre team and on-call fully completed and signed. They also documented the rota for consultant anaesthetists. benefits and risks of the procedure and explained them • There was a service level agreement (SLA) in place with to children’s parents. We observed staff who provided the local NHS trust for specialist advice regarding information to the child in a way they could understand. deteriorating patients such as intensivist, Parents commented that explanation was given to their microbiologist, cardiologist and pharmacy. children in an age appropriate way.

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• We saw a copy of the hospital’s ‘Consent form four- • The response rate for NHS patients was varied in the statement of healthcare professional for adults who are same time period, with the lowest response rate (12%) unable to consent to investigation or treatment.’ This in December 2015 and the highest response rate (70%) documented the best interests’ decision-making of staff in March 2016.The response rate was worse than the for patients who lacked capacity in accordance with the national average between October 2015 and January Mental Capacity Act 2005. 2016. • We did not see a completed ‘“Consent form four’ which • There were four items of rated feedback on the NHS is used when a patient has been assessed as not having Choices website for BMI The Runnymede Hospital capacity to consent for a procedure or operation. between April 2015 and March 2016, three patients were However a member of staff described a recent occasion extremely likely to recommend and one patient were when one had been used for a patient who had extremely unlikely to recommend the hospital. undergone a mental capacity assessment (MCA) which • There were posters in the two wards displaying concluded the patient did not have capacity to consent comments from patients about their experiences of for themselves. care. • Staff we spoke to were aware of DoLS, however staff on • We saw that staff always respected patients’ privacy and the ward told us they had never needed to apply it. They dignity. We saw staff in recovery closing the curtains were able to describe the process of applying for a around patients in recovery to protect their privacy standard authorisation from the local authority. A when they needed to check the operation site. standard authorisation gave permission for hospital • We saw a male nurse caring for patients in recovery and staff to restrict a patient’s liberty who lacked mental because a female patient’s operation site was in an capacity when this was necessary and proportionate to intimate place, a female nurse checked the site instead. keep the patient safe from avoidable harm. This demonstrated that the patient’s dignity was given consideration by the male nurse. Are surgery services caring? • Parents we spoke with told us they were very happy with the care their child was receiving, saying they Good ––– “understood everything that was going to happen and couldn’t fault anything”. • The parents we spoke with praised staff for the way they We rated caring as good because: communicated with them and how they were always • Feedback we received from patients and people, those smiling. One parent commented “staff were excellent”. who are close to them and stakeholders was positive. • We received 34 patient comment cards from patients • Patients were treated with dignity, respect and kindness who recently had surgery at the hospital. We reviewed during all interactions with staff and relationships with these comment cards and only two had negative staff are positive. comments and these were about organisational issue • Staff anticipated patients’ needs and their privacy and and not related to the care they received. Positive confidentiality were respected at all times. comments on the cards included: “Fantastic staff, I was • Patients understood their care, treatment and treated with dignity, respect and humanity, I would feel condition. Patients and staff worked together to plan confident to recommend them,” and “my treatment was care and there was shared decision-making about care first class.” and treatment. • The hospital scored 82% in relation to treating patients with dignity and respect in the Patient-led assessments Compassionate care of the care environment (PLACE) audit which was worse • Between October 2015 and March 2015, the friends and than the national average of 87%. family test for NHS patients scored 100% with the • Understanding and involvement of patients and exception of January 2016 when the score was not those close to them available. This showed that the vast majority of patients • Patient comment cards stated “staff answered to your would recommend BMI The Runnymede Hospital to needs and questions” and “they responded to your their family and friends. 45 BMI The Runnymede Hospital Quality Report 25/01/2017 Sur g er y

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needs and care, when they came into the room they • We heard at a nursing handover, that a patient was were totally focused on my care, it was like I was the struggling with their newly formed stoma, one of the only person important to them at that time also, they nurses suggested contacting the stoma nurse specialist made my husband feel comfortable and managed to to provide support. This showed they cared that the work around him.” patient was anxious and wanted to provide the • These comments reflected patient centred care and appropriate support. involvement of those close to them. • We saw staff in theatres providing emotional support to • We spoke to three patients, who all told us they had patients who were worried or anxious. For example, we been kept well informed at every stage of their care. saw an anaesthetist holding a patient’s hand whilst they • The patients we spoke to all knew the name of the nurse were anaesthetised to provide comfort and reassurance. looking after them. • We saw staff in recovery asking patients if they were • The service involved patients’ relatives and people close warm enough and offering them sips of water to ensure to them in their care. We saw a patient’s relative stay they were comfortable. with them for the majority of the day and we saw staff • In recovery we saw a child was spoken to kindly when involved them in the patients care, for example they awoke from the anaesthetic. describing the checks undertaken before the start of a • We saw a consultant came into recovery and spoke to a blood transfusion. child appropriately and simply, the child’s mother was • We observed staff providing patient’s visitors with hot advised regarding the operation performed. In addition and cold drinks. they advised that they would follow up with further • In most cases, the hospital provided self-paying patients explanation at the outpatient appointment. with a fixed price treatment package. This ensured • The hospital provided counselling services for patients. patients had peace of mind and would not have We saw counselling leaflets and posters around the unexpected costs to their bill. hospital which contained details of how to book an • Written information given to self-paying patients was appointment. very clear of the requirement to pay their bill before • There was a variety of nurse specialists that could be treatment started. accessed at the local NHS trust for example a vascular • One parent told us that they were especially grateful for nurse specialist and diabetic nurse specialist. a twin-bedded room as she was able to take a rest • All patients received a follow up phone call 48 hours whilst her husband accompanied their child in recovery. after discharge from one of the nurses to check on their Both mum and dad were pleased with overall care welfare and recovery. This enabled patients to feel received. supported by staff after they left the hospital. • We observed nurses applying topical anaesthetic cream to children prior to cannulation (introduce a cannula or Are surgery services responsive? thin tube into a vein) in theatre; it was done in a very gentle reassuring manner. Good ––– • Parents were able to escort children to the anaesthetic room to provide support and were able to collect their child from recovery after the operation. We rated responsive as good because: • We saw a hand held computer playing a cartoon was • The needs of different patients were taken into account used to distract children in the anaesthetic room. when planning and delivering services (for example, on Emotional support the grounds of age, disability, gender, gender reassignment, pregnancy and maternity status, race, • We witnessed a patient in theatre undergoing an religion or belief and sexual orientation). operation under local anaesthetic which lasted for one • Facilities and premises were appropriate for the services hour and ten minutes. During the operation staff kept being delivered. the patient informed, reassured and had good banter with the patient about which football team they supported.

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• Waiting times, delays and cancellations were minimal • The hospital used the BMI Healthcare staff planning tool and managed appropriately. Services ran on time. to plan appropriate staffing ratios based on the planned Patients and their relatives were kept informed of any number of patients. disruption to their care or treatment. • We saw that the theatre and ward facilities were • It was easy for people to complain or raise a concern appropriate for the services provided. and they were treated compassionately when they did • The two wards were altered to reflect the needs of the so. There was openness and transparency in how service, for example during our inspection the activity complaints were dealt with. was low so all surgical patients were cared for on • Complaints and concerns were always taken seriously, Burwood ward. This meant the staff from Wentworth responded to in a timely way and listened to. ward went to look after the day case patients on Burwood ward. This saved the expense of having an Service planning and delivery to meet the needs of underutilised ward open and gave staff an opportunity local people to work together. • We saw there was a responsive service for patients who • When children were seen in the outpatient department required urgent admission for surgery, daily 9am head the consultant needed to check with the hospital that of department meetings took place with all there were children’s nurses available prior to booking a departments represented. This enabled all potential date for surgery. admissions for that day and the next five days ahead, to Access and flow be discussed and planned for to ensure that the patient could be admitted safely. • On arrival at the hospital, staff showed surgical patients • Staff in theatres told us until recently theatre lists often to Burwood ward if they were staying overnight and did not end until late at night; this led to tiredness and either Burwood ward or Wentworth ward if they were despondency of the theatre staff. The management having a day case procedure. team introduced a new five day rule which meant all • Children were admitted to Wentworth ward, where four patients that consultants wanted to admit for surgery twin-bedded rooms were allocated close to the nurses’ within five days had to be agreed to by departments. station for children and young people requiring • This ensured better planning of the service and enabled inpatient or day care surgery. Children followed the staff to be used effectively for example staff in theatres same pathway as adults. started their shift later to cover evening operating • Patients got changed and prepared for surgery in their sessions. In addition it enabled pre assessment to be room. Staff then escorted patients to the theatre suite undertaken in a timely way and ensured equipment and for their operation. The majority of patients walked to bed availability. theatre rather than going on a trolley or wheelchair. • Staff told us since the five day rule had been introduced Immediately after surgery, staff cared for patients in the there had been a significant reduction in the late finish recovery room. times within theatres. • Once patients were stable and pain-free, staff took them • Service planning for patients who may require specialist back to the ward to continue recovering. Patients had a input of higher dependency of care was easier to responsible adult to collect, escort and stay with them arrange because of the proximity and links to the for 24 hours if they were a day case. Inpatients stayed on adjoining NHS hospital. the ward for one or more nights after surgery. • The most common operation (236) performed at the • The hospital cancelled 10 procedures between April hospital between April 2015 and March 2016 was a 2015 and March 2016; of these, seven patients were multiple arthroscopic operation on the knee (key hole offered another appointment within 28 days of the surgery). This type of surgery is easy to plan for as the cancelled appointment. patients are usually fit and healthy and did not need to • Throughout our visit, theatre lists generally ran on time. stay in overnight, meaning less pressure on the service. • Referral to treatment waiting times (RTTs) patients • The theatre manager reviewed operating lists in having inpatient surgery at the hospital showed that, on advance. This ensured there was sufficient time to average, 95.7% of patients received treatment within 18 arrange all necessary staff and equipment.

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weeks of referral between April 2015 and March 2016. • We saw a teddy bear was given by recovery staff to This was better than the national target of 90%. The children as a present and to provide reassurance and a worst month in this period was December 2015 where distraction for the child. Children were also encouraged RTTs were met 80% of the time. to take their own soft toy to theatre with them. • Theatre staff participated in an on-call rota. Consultants • There was a dedicated paediatric bay in recovery which were on-call whenever they had a patient in the was decorated in a child friendly way for example hospital. Anaesthetists also participated in an on-call stickers of cartoon characters. rota. This system ensured staff were available should a • There was a small supply of children's toys available, patient need to return to theatre at night or at a and children's channels on TV, a DVD player was weekend. provided. • At discharge, nurses gave patients a direct telephone • We saw how an explanation of a child’s status in the number to the ward in their discharge pack. Patients recovery room was explained to parents with the could call this number to speak to a nurse anytime of analogy of the seven dwarfs, for example the child could the day or night if they had any concerns. We observed a be snoozy or grumpy. This demonstrated that staff were nurse give this information to a patient at discharge. responsive to the needs of parents. • Booking forms are sent to the children's nurses when Meeting people’s individual needs received by the bookings team, to confirm appropriate • Staff told us the hospital could book interpreters for cover is in place. both NHS and private patients. A pre-assessment nurse • We were told when children were pre assessed the pain told us staff identified any language requirements at the score tool was explained with the child in preparation pre-assessment stage. for admission. In addition the nurse discussed with the • We saw the department resource folders contained a list child any preferences, phobias, or requests and offered of staff who spoke different languages, this meant staff a tour of the hospital. could be accessed quickly if required to interpret for • Children were normally nursed by the same nurse who patients. saw the child for pre-admission visit, this meant the • Staff told us that patients with learning difficulties or child had a familiar face and knew in advance who additional needs would also be highlighted at the pre would be looking after them. assessment stage. The purpose of this was to alert However: clinical staff to the patient’s individual needs. This allowed staff to plan effectively, for example by • The hospital did not routinely screen patients for arranging theatre lists in a way that lessened anxiety for dementia as part of pre assessment. This meant staff patients with learning disabilities. were unable to identify patients who may lack capacity • One hundred percent of theatre and pre admission staff early in order to plan appropriate care to meet their had completed dementia awareness training; this was needs. better than the BMI Healthcare target of 90%.Ninty Learning from complaints and concerns seven percent of ward staff had undertaken dementia awareness training, This was better than the BMI • There was a clear complaints management process in Healthcare target of 90%. place; this was articulated to us by the Director of • We saw from a patient comment card that a transgender Clinical Services and the personal assistant (PA) who patient had commented on how staff were diligent to was the administrator for complaints. ensure their privacy and dignity was respected. This • We saw all patient rooms had a patient guide and this demonstrated that each patient’s individual needs were included an opening letter from the Executive Director paramount to the care staff delivered. and a section which covered the formal complaints • We observed nurses explained to children and parents procedure. In addition copies of the BMI leaflet entitled that fire alarms would be tested at 9am to ensure the “Please tell us” were located throughout the hospital to children were not scared. make patients and relatives aware of how they could highlight any concerns.

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• All patients were encouraged to complete a patient • We reviewed five complaint responses; the level of satisfaction survey during or after their admission which investigation and subsequent investigation of learning allowed the hospital to evaluate the service provided to varied. For example the standard of statements taken patients. from staff varied in their quality and when face to face • Hospital managers told us they encouraged staff to meetings had taken place between the complainants identify and address any patient or relative concerns and hospital manager the discussion was not recorded and issues whilst the patient was still in the hospital. in detail. • If required, complaints were escalated to the relevant • In addition one of the complaints we reviewed heads of department, the Director of Clinical Services or demonstrated significant learning was needed. This was the Executive Director whilst the patient or their relative not fully identified and there was not a full action plan was still at the hospital to prevent issues developing into implemented. We saw that learning was identified and a formal complaint. shared locally through team meetings, evidenced by • BMI Healthcare followed a three stage process in dealing minutes of the meetings, however changes to practice with complaints, with clear timeframes set out in BMI as a result of complaints could not be evidenced. Healthcare’s complaints policy. • The responsibility for all complaints rests with the Are surgery services well-led? Executive Director. On receipt of a new complaint the PA to the Executive Director logged the details. Good ––– • An acknowledgment was sent out upon receipt of the complaint explaining the investigation process and timescales of the investigation. The details were then We rated the hospital as good for well led. This was passed onto the relevant head of department(s) to start because; the investigation and produce a draft response. • Staff in all areas knew and understood the service’s • During the complaint investigation the process was vision, values and strategic goals. monitored by the PA to the Executive Director to ensure • There was an effective and comprehensive process in that timescales were adhered to. place to identify, understand, monitor and address • Responses were being provided to a complainant within current and future risks. 20 working days (in line with BMI complaints policy). If a • The leadership team were knowledgeable about quality response was not able to be provided within this issues and priorities, understood the challenges and timeframe a holding letter was sent to the complainant took actions to address them. so that they were kept fully informed of the progress of • Leaders prioritised safe, high quality, compassionate their complaint. care and promoted equality and diversity. • The Executive Director was responsible for final • Leaders modelled and encouraged cooperative, verification of the response and sign-off. supportive relationships among staff so that they felt • Patients were invited into the hospital for a face to face respected, valued and supported. meeting to discuss the investigation findings. • Candour, openness, honesty and transparency were • The hospital told us all complaints were logged onto the evident throughout the service. hospital management system where they could be monitored. Learnings and themes from complaints were Vision and strategy for this this core service shared at monthly head of department meetings, • The service shared the BMI Healthcare vision. This was departmental meetings, clinical governance meetings to provide the best outcomes, the best patient and health and safety meetings. experience and the most cost-effective care. • The hospital received 35 complaints between April 2015 • In addition Runnymede hospital had its own vision and March 2016; this was a decrease from 41 in the which was: to be the private hospital of choice for previous year. consultants and patients in West Surrey by delivering • The assessed rate of complaints was not high when the best possible outcomes and a positive experience compared to other independent acute hospitals the for patients; to consistently deliver a high quality and provider held data for. innovative service, which identified and responded to 49 BMI The Runnymede Hospital Quality Report 25/01/2017 Sur g er y

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the needs of customer; to be the employer of choice in • We saw from meeting minutes that, patient satisfaction, West Surrey for both clinical and non-clinical personnel, incidents, infection prevention and control, complaints, attracting the best staff and sustaining a team of the risk register, trends, external/national guidance and motivated and talented individuals and promoting an new legislation, and clinical performance/compliance environment that continued to nurture. were discussed at the clinical governance meetings. • Their strategy aimed to further develop services for • Monthly quality and risk reports were produced which privately insured, self-funding and NHS patients by included National Midwifery Council referrals, further improving their quality standards, developing supervision of consultants for safeguarding and other existing services and introducing new services. incidents. These reports were all reviewed and signed • We asked four members of staff and all four could tell us off by the Executive Director. what the vision was. This meant the vision had been • The hospital had started a children’s steering group in embedded with these staff members. February 2016. We saw the agenda which included and • The executive team told us about areas they were was not limited to topics such as terms of reference, working to improve. In surgery for example we saw patient safety, children’s incidents, and patient evidence of approved funding for a carpet replacement experiences. However, there were no minutes to support programme. the meeting. Terms of reference for this group stated that it will meet three times annually. However, the Governance, risk management and quality documentation provided by the hospital showed only measurement for this core service an agenda for the February meeting. • We saw a diagram of the hospital’s governance • The blood transfusion committee, medicines structure. management, health and safety and infection • The hospital had a quality and risk manager to oversee prevention and control committees met quarterly. hospital-wide quality and risk, who reported to the • The BMI Healthcare group produced a monthly group director of clinical services. clinical governance bulletin. This contained details of • Surgery staff reported to either the ward manager or incidents, never events, and internal quality inspection theatre manager. Managers met on a monthly basis and visits from hospitals across the BMI Healthcare group. reported to the director of clinical services. The The purpose of the newsletter was to share learning hospital’s medical advisory committee and clinical from governance issues in all hospitals across the group. governance committee also provided quality and safety • The hospital’s MAC provided the formal organisational assurances to the executive team. Consultant surgeons, structure through which consultants communicated. anaesthetists, ward manager and theatre manager The MAC advised the executive team and worked to represented surgery on the medical advisory committee maintain high standards and improve the quality of (MAC). services. The MAC met every three months. • The executive team consisted of Director of Clinical • We saw from the MAC minutes that the committee Services, Operational Services Manager, Hospital reviewed consultant’s practicing privileges. This Administrator, PA to the Executive Director and the provided the executive team with assurance that Executive Director. consultants were competent to perform surgery at the • Clinical governance responsibility was shared between hospital. the Head of Clinical Services and the Quality and Risk • We saw from the March 2016 meeting minutes that one Manager. consultant’s practicing privileges were to be delayed • The hospital’s clinical governance committee met every until confirmation of the consultant’s role in the NHS two months. Reports from other committees were hospital. circulated prior to the meetings to ensure staff were • We reviewed the hospital’s risk register, although there prepared. The clinical governance committee was was no local risk register specifically for surgery. We saw responsible for ensuring the hospital used appropriate that some of the areas of risk we identified, such as a systems and processes to deliver safe, high quality lack of intumescent strips on fire doors, were on the risk patient care. register. The executive team told us that there was a rolling programme to replace them.

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• The risk register also aligned with areas the executive • There was a staff turnover of 2.4% for theatre nurses team told us they were working to improve. This showed between April 2015 and March 2016; this rate was not the executive team understood the areas of risk relating high when compared to other independent acute to surgery. The Executive Director had overall ownership hospitals the provider held data for. for the risk register; it was embedded in quality and risk • There was a 40% staff turnover for operating report, and discussed at regional meetings. department practitioners and health care assistants in • We saw that the risk register was generally used for theatre during the same time period. The rate was issues when control lay outside the hospital. The higher than the yearly average when compared to other executive team told us that they would not necessarily independent acute hospitals that the provider held data put something on the risk register if it could be resolved for. locally. • There was a 31.8% staff turnover for inpatient nurses in • We saw a comprehensive clinical audit schedule to the same time period reporting period. The rate was provide quality assurance. Audits related to surgery higher than the average turnover of this staff group included infection prevention and control, hand when compared to the other independent acute hygiene, venous thromboembolism (VTE) screening, hospitals that the provider held data for. theatres, and the WHO checklist for safer surgery. Public and staff engagement • The hospital utilised daily communication meetings (huddle) as an effective way to share information and • The hospital monitored staff feedback through an drive continuous improvement. anonymous annual survey and was committed to • The hospital worked under the guidance of the BMI responding positively to feedback. The results of the corporate policy for the care of children. survey were fed back to the team through staff briefings • There was a hospital children’s and young person’s(CYP) held by the Executive Director. advisory group which met quarterly and was • Staff loyalty was rewarded through long service awards responsible for ensuring current BMI corporate policies – the PIN Awards. and procedures were implemented and compliance was • All staff were given the opportunity to seek funding to monitored, and that national guidance and legislation support their professional development and the was discussed and shared with staff. hospital has funded a wide range of courses for the • In addition the committee advised on any identified benefit of the individuals and the hospital. risks associated with children’s services in the hospital • The hospital implemented the BMI appraisal policy to and recommended actions to reduce or minimise risk ensure that all staff understood their personal and reviewed any clinical incidents in relation to objectives, and how they fit with the departmental and children and young persons. This group reported into to hospital objectives and vision. the hospital clinical governance committee. • Social interaction was encouraged through a range of Leadership / culture of service related to this core events for example the pin awards, above and beyond service awards and charitable initiatives to encourage staff engagement in a social context. • We saw leaders valued and respected staff. Staff • Opportunities for staff to engage with the management generally felt valued and told us that leaders were team occurred daily informally or through department visible and approachable. Staff told us they felt meetings and staff forums. supported by their managers and colleagues. • The hospital actively engaged to seek the views of • Staff told us one of the best things about working at the patients and their relatives. We saw patient satisfaction hospital was their colleagues. We saw that staff worked questionnaires available throughout the hospital for well together and respected each other and worked as a patient feedback. team. • The hospital also sought feedback through the NHS • There was a culture of transparency and honesty choices website and the NHS friends and family test. amongst staff. Staff told us managers encouraged and • The hospital’s website provided a range of information supported them to report incidents. about the services provided. It also provided details of

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consultants who worked at the hospital and their Innovation, improvement and sustainability credentials. Members of the public could use this • Development plans in surgical services for the future information to help them decide whether they wanted included implementation of ambulatory care pathways. to receive treatment at the hospital. • The hospital took part in BMI Healthcare provider visits. • We saw that there were no photographs of the This was where staff from other BMI Healthcare paediatric nurses on the wall on Burwood ward; this hospitals carried out internal quality inspections. meant the paediatric nurses may feel excluded and Provider visits gave the hospital feedback to enable a undervalued continuous cycle of improvement

52 BMI The Runnymede Hospital Quality Report 25/01/2017 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

Safe Good –––

Effective Not sufficient evidence to rate –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

The outpatients and imaging departments were opened Information about the service Monday to Friday, 8am to 8pm and Saturday, 9am to 1pm. Inpatient physiotherapy services were available seven days BMI The Runnymede Hospital is an independent hospital a week. which forms part of the BMI Healthcare Limited Group. It is situated in the grounds of St Peter's Hospital, Chertsey and We spoke with 12 patients, and two parents. We also spoke linked to St Peter's by a corridor. The hospital provided an with 23 staff members, ranging from managers, care outpatient service for various specialties which was not assistants, nursing staff, radiographers, consultants and limited and included diagnostic imaging such as x-ray, support staff. We reviewed documentary information such ultrasound and mammography, ear, nose and throat (ENT), as meeting notes and policy papers. In addition, we physiotherapy assessment and treatment, orthopaedics observed activities, staff interaction with people using the and dermatology. There were 33,590 outpatient service, checked equipment and the patient environment, attendances between April 2015 and March 2016, of which and reviewed five sets of patient records. 91% were privately funded (self-paying or through medical insurance) and 9% were NHS funded appointments. Of the 33,590 attendances, 1% was children age 0 to 2 years, 6% was 3 to 15 years and 1% was age 16 to 17 years. Outpatient facilities comprised a waiting area, eight consultation rooms and one treatment room located on the ground floor. The treatment room was used for minor procedures such as wound checks, dressings and removal of sutures. The imaging department included magnetic resonance imaging (MRI) and computerised tomography (CT) scanning, ultrasound, fluoroscopy (ophthalmology rooms) and an x-ray area. MRI and CT scanners were part of a mobile service sited in the hospital grounds and provided by an external contractor. This facility was not part of this inspection. There was a physiotherapy office and four treatment rooms including a gymnasium. The imaging and physiotherapy departments were located on the ground floor, and both had their own small waiting areas.

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Outpatients and diagnostic imaging

Summary of findings Are outpatient and diagnostic imaging services safe? Overall, we rated the outpatients department and diagnostic imaging as good. This was because: Good ––– • The outpatients and diagnostic imaging departments provided a broad range of services for We rated the services as good for safety because: both privately funded and NHS funded patients. The • People were protected from avoidable harm. There patients we spoke with were complimentary about were effective processes and systems in place to the care, treatment, and service they had received in mitigate risks for the prevention and control of infection, both departments. safeguarding people from abuse and medicines • Staff were competent and worked to national management. guidelines, and ensured patients received the best • There were appropriate safeguarding arrangements that care and treatment. were delivered in line with current national guidance. • The culture within both departments was patient Staff demonstrated a good understanding of the focused, open and honest. The staff we spoke with hospital policy and there were embedded systems to felt valued and worked well together. Staff followed identify and act upon any concerns about patients’ policies and procedures to manage risks and made safety. sure they protected patients from the risk of harm. • Openness and transparency about safety was • There were short waiting times for appointments. encouraged. Staff understood their responsibilities and Private patients were seen within one week, and NHS were supported to report concerns, incidents and near patients were usually seen within four weeks of misses. Opportunities to learn from incidents locally and referral. Patients described that they could get corporately were identified. appointments with their chosen consultant and were However: seen on time. • Flooring in some of the consultation rooms did not • Patients we spoke with told us they were treated with comply with Health Building Note (HBN) regulation. dignity and respect. All patient feedback during the • Some clinical staff who undertook assessment of inspection was positive. They described the service children were not trained to safeguarding children level as ‘first class’, ‘very good’ and ‘professional’. three • Both departments were visibly clean. • The children’s waiting area was limited and there was a lack of age appropriate toys. The area was very small and was combined with the main waiting area for adults. Incidents • No never events were reported in the period between April 2015 and March 2016. Never events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

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Outpatients and diagnostic imaging

• There were no serious incidents reported for outpatient • Cleaning schedules with daily tasks were clearly and diagnostic imaging services between April 2015 and displayed, dated and signed in the five consultation March 2016. rooms and treatment room. • Between April 2015 and March 2016, 15 clinical incidents • Staff cleaned the couches with detergent wipes and and 12 non-clinical incidents were reported within prepared them with clean linen for patients to lie on outpatient and diagnostic imaging services. There were between each patient. The couches were intact and no themes apparent and the rates of incidents per 100 clean. outpatient attendances were lower when compared to • In the five consultation rooms we inspected, we saw similar independent hospitals. hand wash sinks had taps which can be operated • Staff understood how to report an incident and without the use of hands. This complied with HBN 00-10 explained the process that they would follow. Staff Part C: Sanitary Assemblies. The HBN states that, ‘basin reported incidents using a paper based reporting taps used in clinical areas and food-preparation and system. The information was transferred onto an laboratory areas are required to be operated without electronic based system by the quality and risk the use of hands.’ They complied with the HBN 95 manager. Incidents were discussed at staff meetings. standard as the hot and cold taps were separate. • Staff described an incident where a consultant looked at • Staff were bare below the elbow and demonstrated an patients’ records of another consultant, which was a appropriate hand washing technique in line with ‘five breach of confidentiality. In response to this, staff took moments for hand hygiene’, from the World Health action to replace the cupboard with a new lock, and the Organisation (WHO) guidelines on hand hygiene in keys were made accessible to nursing staff. This was health care. Information was displayed demonstrating documented in the January 2016 staff meeting notes. ’five moments for hand hygiene’ near handwashing This meant that staff reported incidents and learned sinks. from them by taking the appropriate action. This was in • We noted that all personal protective equipment (PPE), line with the hospital incident policy. for instance, disposable gloves were available in the five • Staff confirmed that imaging incidents were reported to consultation rooms. Disposable aprons were also noted the Care Quality Commission (CQC) under the Ionising in the treatment room. This met the Royal College of Radiation (Medical Exposure) Regulations (IRMER). The Nursing Essential Practice for Infection Prevention and Radiation Protection Adviser (RPA) carried out a regular Control, Guidance for Nursing Staff. review in relation to radiation doses and any anomalies • We saw sharps bins available in treatment areas where would be reported back. We saw that the last review sharps may be used. This demonstrated compliance was carried out on 8 May 2016 and the radiation dose with health and safety regulation 2013 (The sharps was within an acceptable range. regulations), 5 (1) d. This required staff to place secure • Staff described the basis and process of duty of containers and instructions for safe disposal of medical candour, Regulation 20 of the Health and Social Care Act sharps close to the work area. We saw fully completed 2008. This relates to openness and transparency and labels on sharps bins which ensured traceability of each requires providers of health and social care services to container. notify patients (or other relevant persons) of ‘certain • We saw ‘sharps’ audit compliance rates improved from notifiable safety incidents’ and provide reasonable 73% to 93% between May and July 2016. These audits support to that person. Service users and their families were discussed in staff meetings, heads of department were told when they were affected by an event where meetings and daily handover meetings. The results were something unexpected or unintended had happened. displayed on staff notice boards. The hospital apologised and informed people of the • A biohazard spill kit (containing relevant equipment to actions they had taken. manage blood and other bodily fluid spillages) was located in the treatment room that was secured steadily Cleanliness, infection control and hygiene on a cabinet, and was accessible in the event of a • We found the outpatient and imaging department spillage. waiting areas, consultation rooms and treatment room • Infection control audits were completed, including hand were visibly clean and tidy. hygiene. Monthly audit results for hand hygiene

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Outpatients and diagnostic imaging

demonstrated that consultants including imaging minimum height of 100mm allow for easy cleaning’. doctors were compliant ranging from 30% in January However, the hospital confirmed there is a planned 2016 to 90% in August 2016, which showed much programme of works to replace the flooring by May improvement in hand hygiene practices. All other staff 2017. were compliant ranging from 90% in January 2016 to Environment and equipment 96% in August 2016. We saw audit results discussed in the hospital clinical governance meeting notes and • We saw two resuscitation trolleys, one was for paediatric actions to encourage 100% compliance. We saw results use and the other for adult use. They were situated side displayed on staff notice boards. During inspection, we by side and were located in the waiting area of the saw all clinical staff in outpatient and imaging including outpatient department. The trolley was tamper proof physiotherapy were ‘bare below the elbow’ and and all consumables were in date. Staff checked the complied with hand hygiene in line with the hospital’s trolley daily; we saw up-to-date complete checklists to hand hygiene policy. confirm this was done. • We found the x-ray room and ultrasound room visibly • One defibrillator was shared between both resuscitation clean and tidy. Within the x-ray room, a diagnostic trolleys. However, there were no records to indicate that imaging department environmental checklist included the defibrillator on the resuscitation trolley was serviced daily tasks to be checked for example, the x-ray unit, or safety checked. The manager informed us the image intensifier and lead aprons. We saw completed defibrillator was new and assured us that a safety check checklists on the days the department was in use. would be arranged immediately. We saw records that it • We saw disposable curtains used in clinic rooms, dates was new and fit for purpose. This was escalated to the on them indicated they had been changed within six head of department who told us that there was a review months. of all equipment to be completed by end of August • We saw a cleaning schedule which was up-to-date and 2016. signed for the toys in the limited children’s area • We saw all other equipment labels demonstrated that combined in the main waiting area. they were within service date and had been PAT tested. • Patient led assessments of the care environment • The manager told us consultants did not bring in their (PLACE) score for cleanliness was 99%, higher than the own equipment and there was no specific policy in England average of 98%. place for consultants bringing in their own equipment. • We saw two out of five consultation rooms did not However we were told that consultants were aware that comply with the Department of Health Building Note equipment would need to be fit for purpose if they were (HBN). The rooms had carpets and did not comply with to use their own equipment. HBN 00-09: ‘Infection control in the built environment • Staff told us the mammography unit located in the x-ray Hospital building note (3.82) which states that carpets room was ageing. However, checks were undertaken to should not be used as this area has a high probability of ensure it remained fit for purpose. We saw the body fluid contamination’. However, the hospital equipment was in service date. We saw the hospital risk confirmed there is a planned programme of works to register June 2016 identified the ageing mammography replace the flooring by May 2017.Staff told us that unit. The hospital planned to replace this but we were clinical procedures were not carried out in carpeted not provided with a replacement date. rooms until the flooring was replaced. Medicines • One of the five consultation rooms had laminate flooring and did not have a continuous run between the • A British National Formulary (BNF), which is a floor and wall. This did not comply with HBN 00-10 Part pharmaceutical reference book, was found in five of the A: Flooring, where the floor joined to the wall. The HBN consultation rooms and treatment room we inspected. states that, ‘In clinical areas and associated corridors, In one room, where children were seen, there was an there should be a continuous return between the floor additional paediatric BNF. All BNFs seen were valid until and the wall. For example, coved skirting with a September 2016.

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Outpatients and diagnostic imaging

• Records of daily temperature checks were completed in system when leaving the computer station at the the x-ray and treatment rooms, medication cupboard nursing staff desk. This meant that staff complied with and fridge, and were within the limits. This was to the hospital information governance policy, including ensure the correct temperature was maintained and the Data Protection Act (DPA). medication was stored safely. • Information provided to us before the inspection • Prescription pads were stored safely and secured in a identified that data was not captured if patient records locked cupboard and the duty lead nurse had access to were not available at the time of appointment in the key. There was a process where prescription pads outpatients and imaging department. Staff informed us were kept safe. We saw reference log numbers that it was rare that patients were seen without their completed for prescription pads. care records for NHS and private patients. Staff said that • We saw medicine safely stored and secured in the as clinics were prepared in advance, they were able to imaging department in a locked cabinet, and the duty request the hospital medical records department for radiographer had access to the key. care records and had access within 48 hours. This meant that patients received safe and timely care. Records Safeguarding • We saw examples of checklists used that were adapted from five steps to safer surgery, based on the World • There was a BMI Healthcare Group Safeguarding Health Organisation (WHO) Surgical Safety checklist. Children policy and a Safeguarding Adults policy. This included ‘sign in’ checks where the patient identity • Posters displayed ‘What to do if you’re worried about an and operative site was confirmed and ‘sign out’ checks adult’s welfare’ in the five consulting and treatment where the instruments used were counted back and any rooms, and throughout the outpatient and imaging specimens are labelled and sent to the laboratory. We departments. These showed flowcharts on action to be saw these forms completed in five patient records who taken and included contact details of who could be had a minor procedure. contacted for advice. These were displayed to remind • We saw all five patient records were fully completed, for staff of the correct reporting processes. example patient allergies, regular medication and • The Director of Clinical Services was the hospital’s adult previous operations. Risks and benefits were also and children safeguarding lead and had overall recorded including the procedure being explained to responsibility for safeguarding within the hospital. the patient. • The Children's Services Clinical Lead also supported the • We saw all five patient records were legible, dated, Director of Clinical Services for safeguarding children signed, intact and stored securely in a locked cabinet. within the hospital. Staff returned the records to the medical records • Staff we spoke with could identify the safeguarding department on-site the same day after patients’ leads and described how to report safeguarding attendance. Records were then kept at the hospital for concerns. ten months and then sent off site for storage. We saw a • All consultants undertook level three safeguarding track and trace system in practice which meant staff training as part of their mandatory training in their NHS knew where records were and were able to access hospital. records when required. • All contracted paediatric nurses were trained to • Hospital patient records were not removed from site by safeguarding level three. a consultant. Should a consultant need to take the • There were no safeguarding concerns reported to CQC hospital records off-site, advance permission was in the reporting period between April 2015 and March sought in accordance with their care records policy. 2016. • Staff were provided with individual accounts to access • One agency outpatient nurse told us they had the electronic hospital outpatient appointment system. undergone level two safeguarding training. However the We observed that staff logged out from the electronic nurse told us they undertook weighing and measurement of height for children. This did not comply with the Intercollegiate document 2014 and the hospital safeguarding children policy, which state “level 3 -

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Outpatients and diagnostic imaging

clinical staff working with children, young people and/or (IRMER) for patient’s examinations. A radiation their parents/carers and could potentially contribute to protection supervisor was on site for each diagnostic assessing, planning, intervening and evaluating the test and a radiation protection adviser was contactable needs of a child or young person and parenting capacity if required, which complied with IRMER. where there are safeguarding/child protection • The Radiation Protection Advisor performed an annual concerns”. quality assurance check on equipment in the diagnostic imaging department. Departmental staff also carried Mandatory training out regular checks. This helped to assure the hospital • The overall hospital mandatory training report that equipment was working correctly and these demonstrated 92.4% compliance. mandatory checks were in line with Ionising Regulations • Some of the topics covered by mandatory training 1999 and the IRMER 2000. We saw records of these included fire, infection control, manual handling, checks during our visit. safeguarding, and equality and diversity. • Signs advising women who may be pregnant to inform • All new staff, including agency staff, completed an staff were clearly displayed in the diagnostic imaging induction. Topics were not limited and included cardiac suite, in line with best practice. This helped the hospital arrest procedure, fire, dealing with complaints, data prevent potentially harmful exposure to radiation to protection and the department layout. This ensured unborn babies. that all staff on site were familiar with local procedures Nursing staffing and received the same training. • Training was available through a mixture of e-learning • Data provided to us before inspection indicated the method and face to face training. Staff told us they were vacancy rate of two full-time equivalent (FTE) posts for able to access courses on planned dates and via the outpatient nurses giving a vacancy rate of 50%. There hospital intranet. Staff were given protected time to were two FTE posts vacant for outpatient health care complete training. assistants (HCA’s) giving a vacancy rate of 67%. However, we were told recent recruitment meant that all Assessing and responding to patient risk vacancies in outpatient would be filled by October 2016. • Staff were knowledgeable about the actions they would Bank and agency staff were used to fill the gaps and this take if a patient deteriorated in the outpatient had ensured sufficient staff were on duty. department. Staff explained the process and were • The manager told us there were always two nurses and aware of where the nearest resuscitation trolleys were two care assistants working at any shift to maintain safe located. staffing levels. • Immediate or emergency assistance could be • Data provided to us before the inspection indicated that summoned by the use of the hospital ‘crash call’ or the hospital used a high number of bank and agency resuscitation team. Medical assistance was provided by staff in the outpatient department between April 2015 the resident medical officer (RM) and the patient’s and March 2016. The bank to agency ratio in the last consultant when required. three months of the reporting period was 1 to 3.17 and • We observed good practice for reducing exposure to 100% use of bank HCA’s. The manager told us bank and radiation in the diagnostic imaging departments. Local agency staff were used to cover any holiday, sickness rules were available in all areas we visited and signed by and vacancies. They would see a reduction in this use all members of staff, which indicated they had read the when the new recruits started work by end October rules. Diagnostic imaging staff had a clear 2016. understanding of protocols and policies. Protocols and • Bank and agency staff who worked in the outpatients policies were stored in folders in each room. and imaging departments were mostly established. This • We observed good radiation compliance during our meant patients could be assured that staff were familiar visit. The department displayed clear warning notices, with the service provided and the needs of the patients. doors were shut during examination and warning lights • The manager informed us that sickness rates in the were illuminated. We saw radiographers referring to the outpatient and imaging department were low. Ionising Radiation (Medical Exposure) Regulations 2000 Information provided prior to inspection demonstrated

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Outpatients and diagnostic imaging

the sickness rate was 0% for nursing staff and care Major incident awareness and training assistants between April 2015 and March 2016, with the • Staff were aware of actions to take in the event of a exception of January (just above 25%) and March 2016 major incident, including if there was a fire. One staff (5%), both months for care assistants. member was able to describe in detail the actions they Medical staffing would take and the training they had. This included taking part in role play as a patient. We were informed • Each consultant attended the outpatient department that this allowed the staff member to be able to on set days at set times. This meant that the reassure a patient in the event of an emergency and department knew in advance which consultant was empathise with any anxieties they may feel. This meant attending and were able to allocate nursing staff that staff complied with the hospital emergency policy. appropriately to the clinics. • The hospital employed 168 medical staff with practicing privileges in the reporting period between April 2015 Are outpatient and diagnostic imaging and March 2016, of whom 18 had their practicing services effective? privileges removed due to retirement from private practice, non-compliance of paperwork or no longer Not sufficient evidence to rate ––– worked at BMI The Runnymede. Practicing privileges of 25 medical staff were suspended due to The effective domain for outpatient and diagnostic imaging non-compliance of paperwork, no longer worked at BMI services was inspected; however, this domain is not The Runnymede or general medical council currently rated. (GMC)/safeguarding issues with an NHS Trust. The hospital reported no medical staff on supervised • The outpatients and imaging department planned and practice and any medical staff under supervised delivered care and treatment in line with current practice in their NHS post were suspended from their evidence-based guidance, standards and best practice. practising privileges at BMI The Runnymede. • Staff had the right qualifications, skills, knowledge and • The granting of practising privileges is a well-established experience to do their job. The learning needs of staff process within the independent hospital healthcare were understood. Staff were supported to participate in sector whereby a medical practitioner is granted training and development. permission to work in a private hospital or clinic in • Multi-disciplinary teams worked well together to independent private practice, or within the provision of provide effective care. community services. There should be evidence that the • Consent to care and treatment was obtained in line with provider has complied with legal duty to ensure that the legislation and guidance. regulation 19 in respect of staffing and fit and proper Evidence-based care and treatment persons employed are complied with. Where practising privileges are being granted, there should be evidence • We saw examples of policies and procedures in the of a formal agreement in place. We saw that these hospital referring to professional guidance. For example, agreements were in place for all medical staff with the chaperone policy referred to professional guidance practising privileges and there was a robust process in from the Royal College of Nursing (Chaperoning: The place to ensure medical staff had the requirements to role of the nurse and the rights of patients, 2002). provide safe care. Posters informing patients of their entitlement to have a • Consultants in clinic were supported by a resident chaperone and how to request one were clearly medical officer (RMO) if required. RMOs were provided displayed in the waiting area by one agency. They worked a two-week on and • Staff followed the National Institute for Health and Care two-week off rotation for a period of at least six months. Excellence (NICE) and Royal College of Radiologists Rotas were set by the agency and sent to the hospital in (RCR) standards. For example, we saw staff monitored advance. Emergency RMO to cover sickness was provided seven days a week.

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radiation doses which ensured that patients did not Patient outcomes receive unnecessary radiation doses. This demonstrated • The hospital participated in the National Joint Registry the department monitored compliance with the audit where data for all joint replacements was guidelines. submitted. This allowed the hospital to collect data • New NICE guidelines were assessed within the hospital about joint replacement surgery to provide an early for their relevance by the medical advisory committee warning of issues relating to patient safety. The primary (MAC) and cascaded, including to consultants. purpose was to monitor the outcomes achieved by • The hospital had a MAC, which met quarterly to review brand of prosthesis, hospital and surgeon, highlight clinical performance, incidents or complaints and where they fell below expected performance, and obtain feedback from the consultant body on new allowed prompt investigation and follow-up action. developments and initiatives from within the various • The hospital also participated in Patient Reported specialties. Outcome Measures (PROMs) for three clinical • Staff accessed policies from the hospital intranet site. procedures for NHS funded patients such as hip and We saw how policies were disseminated to staff to read, knee replacements and groin hernia. The hospital sign and implement using tracker documents to confirm provided provisional data for this which was published understanding and their compliance. on 12 May 2016. PROMs calculate the health benefits • Staff undertook numerous clinical and non-clinical after surgical treatment using pre-and post-operative audits. These were not limited and included infection surveys. This meant that the hospital was able to assess prevention and control, cleaning, hand hygiene and the quality of care delivered to patients. radiation doses. We saw a regular audit programme and • The hospital participated in the National Clinical Audit observed examples of audit results shared in team Programme (NCEPOD). meeting notes and on staff notice boards. Competent staff Nutrition and hydration • The appraisal rate provided before the inspection was • Staff told us patients were offered refreshments if they 33% for outpatient and imaging staff. However, the head were delayed being seen, although the maximum of department confirmed the rate had improved waiting time was usually 10 to 15 minutes. We saw following the introduction of the new electronic system. self-dispensing hot drinks and water units available to We saw 100% completion rate and staff we spoke with patients in the waiting area. told us they had up-to-date appraisals • Refreshments were offered to patients who had a minor • The head of department confirmed that all professional procedure or if the patient had undergone a fasting updates and best practice for physiotherapy staff were blood test. If a patient needed additional food, staff checked by the hospital including training records to could request a sandwich or toast from the hospital ensure patients were treated by competent staff. kitchen. • The manager informed us that competencies were • This meant patients’ nutrition and hydration needs were maintained by completing mandatory training. All new met as required when attending the outpatient staff members were inducted corporately and were department. supernumerary until they had completed their Pain relief induction. One bank HCA told us they were supernumerary until they had completed their • Staff told us they were rarely required to administer pain induction. relief due to the nature of the clinics. However, nurses • Staff confirmed they had protected time to complete asked patients about pain during appointments. competency training. This included IRMER training for Nursing staff informed the consultant if the patient had radiographers. complained of pain to them. • All doctors with practising privileges were at consultant • Pain assessments were documented in patient care level and were registered with the General Medical records when they attended for a minor procedure. We Council (GMC). This meant patients could be assured reviewed a random sample of five records which that they were treated by registered practitioners. evidenced this.

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Outpatients and diagnostic imaging

• We saw from the MAC minutes that some consultants • We spoke with a range of clinical staff who all clearly had been suspended from practicing at the hospital, as described their responsibilities in ensuring patients they had not provided the necessary paperwork. consented when they had capacity to do so or when decisions were made in their best interests. This met Multidisciplinary working (related to this core service) with the hospital consent policy. • Staff told us there was a good working relationship with • Gillick competence is concerned with determining a the reception, imaging, physiotherapy, administrative child’s capacity to consent to medical treatment or and cleaning teams. We saw evidence that the nursing intervention. Staff we spoke with demonstrated team and reception team communicated well together awareness of the hospital consent policy and how they and supported each other. Staff told us that they were would apply the Gillick competence test for children and supported by their peers and other staff groups within young people when required. We did not observe any the hospital. We heard positive feedback about the situations where the Gillick competency test needed to “good teamwork” throughout the departments be applied during inspection. generally. • The hospital had a Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLs) Seven-day services policy. This showed a March 2016 review date and was • Outpatients and imaging were open five and a half days therefore out of date. We escalated this to the hospital a week as was the outpatient physiotherapy service. during inspection and they took immediate action to Inpatient physiotherapy and pre-assessment services update the policy. We did not observe any situations were available seven days a week. where this policy needed to be applied during the inspection. Access to information • The hospital confirmed that copies of NHS records were Are outpatient and diagnostic imaging kept on site for ten months and original records would be returned to the relevant NHS hospital the day after services caring? the outpatient appointment. Staff told us NHS records were always available for appointments. Good ––– • Consultants were responsible for their own records relating to private patients as part of holding practising We found outpatient and diagnostic imaging services to be privileges where they must also be registered as good for caring because: independent data controllers with the Information • Patients were positive about the way staff treated them Commissioner’s Office (ICO). and found staff to be professional, attentive and • Imaging staff were able to access information from other welcoming. hospitals through the use of a picture archiving and communication system (PACS). This provided • Patients were involved in decisions around their care convenient access to images when required. and treatment and found leaflets informative regarding any potential surgery. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Compassionate care • Staff told us consent was obtained from a patient before • We received 10 comment cards from patients related to a minor procedure was carried out in the outpatients experiences in the outpatient and imaging departments. department. This consisted of a written consent and a • The comments were very positive and praised the copy was kept by the patient and consultant. hospital staff and environment. Patients talked about • We reviewed a random sample of five patient records staff being, “kind and caring”. One physiotherapy patient that had undergone a minor procedure and noted that we spoke with said the service was “first class”. patient consent was obtained as required. The risks and benefits were noted on the document.

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Outpatients and diagnostic imaging

• Several patients told us that staff and their consultant • Patients told us that staff and consultants working in the had the time to explain things in detail and allowed time outpatient clinics were approachable and “had the time for any questions. Patients reported feeling part of the to explain everything”. Information such as side effects decision-making about their treatment and care. of medicine was also made clear. • Consulting and clinical treatment room doors were kept • We saw relatives who were invited to accompany closed, and staff knocked before entering clinic rooms patients into consultation rooms, which indicated that to maintain patients’ privacy. All clinic room doors had the hospital encouraged a friend or partner to attend ‘free/engaged’ signs and we observed staff using these. the appointment in order to provide emotional support. • We saw curtains drawn in the imaging department’s changing facility to maintain patient’s dignity. Are outpatient and diagnostic imaging • Patients told us staff were professional, attentive and welcoming. One patient who had received services responsive? physiotherapy treatment for one year described the service and care as ‘first class’. Good ––– • We observed staff to be friendly and professional when they spoke with patients. We saw staff who were polite We found outpatient and diagnostic imaging services to be and respectful of confidentiality. Patients were able to good for responsive because: have conversations with staff without being overheard • Services were planned and delivered in a way that met and minimal patient identifiable data was discussed. the needs of the local population. The importance of • The NHS friends and family test (FFT) scores in the flexibility, choice and continuity of care was reflected in reporting period between October 2015 and March 2016 the services. were 100%. FFT is a national survey that asks for • Patients were kept well informed of waiting times in patients’ views after receiving care or treatment across clinics and delays rarely occurred. the NHS. The survey was created to help service • Actions from concerns and complaints were dealt with providers and commissioners understand whether their effectively in a timely manner and feedback was used to patients are happy with the service provided, or where improve the quality of care improvements are needed. • Patients were informed about relevant fees for their Understanding and involvement of patients and those consultation before they attended for their close to them appointment. • All patients we spoke with told us they received clear However: and detailed explanations about their care and any • All written information, including pre-appointment procedures they may need. information, leaflets and signage was in English only. • Patients told us they were informed about the fees for their consultation before their appointment. This meant Service planning and delivery to meet the needs of patients received appropriate information in relation to local people costs to enable them to make an informed decision • The hospital had service level agreements (SLAs) in about their appointment. place with a local NHS hospital with regards to some • We saw a variety of health-education literature and services, for instance magnetic resonance imaging (MRI) leaflets produced by BMI. Some of this information was and computerised tomography (CT) scans. This general in nature while some was specific to certain demonstrated that the hospital worked with local conditions. This literature was available in all waiting providers to ensure patients received a streamlined areas of the outpatient departments. service. Emotional support • The hospital had good working links with the local clinical commissioning group (CCG), who set criteria

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Outpatients and diagnostic imaging

within the contract with the hospital for NHS patients. contact the patient directly to make an appointment. This meant local commissioners and other providers This meant there was a reduced risk in delays to patient were involved in planning services to meet the needs of care and treatment and patients were able to access the the local population. relevant services. • Staff told us when a new consultant started at the Meeting people’s individual needs hospital, the consultant liaised with the head of department to ensure a consultation room was • Free car parking was provided on-site for the available. Some consultation rooms were used for convenience of patients and visitors. specific specialties, for example ear, nose and throat • Another patient told us that they were given good (ENT). This meant consultants would be able to work in advice and information, including a leaflet about the an appropriate room according to their specialty and pre-procedure preparations, the procedure and staff could be arranged to support and deliver the information for when they were discharged from the service. hospital. This meant patients were fully informed of their care and treatment. Access and flow • Leaflets provided were in English language only. • A legal requirement by NHS England gives patients the However, staff told us that they rarely had the need to right to access services within a maximum waiting time. provide leaflets in a different language and could access This applied to NHS funded patients only. leaflets in a different language when required. • The hospital met the target of 95% referral to treatment • A telephone interpretation and translation service was (RTT) waiting times for non-admitted patients. This was provided by an external company. Staff we spoke with for patients beginning treatment within 18 weeks of told us that they could access the service when referral for each month in the reporting period between required. April 2015 and March 2016, • A ramp was provided for wheelchair users at the front • Staff confirmed that a patient’s first appointment was entrance of the main building to access the outpatient booked through the national enquiry centre (NEC). With department. There was a toilet with facilities for people the exception of choose and book NHS patients, living with a disability in the waiting area and a suitable appointments were booked through the NHS referral changing cubicle in the imaging department. system. Follow up appointments were booked while the • A hearing loop was available in the outpatient patient was still at the hospital. Patients were informed department for patients living with hearing difficulties. what days the consultant had a clinic and the time of This meant some adjustments had been made to the appointment was flexible to meet the patients’ remove barriers and meet individual needs. needs. We observed this. • Weight limits on the x-ray and ultrasound equipment • Patients felt that the booking system for appointments meant that patients over this limit would need to attend was excellent. One told us they were referred by their GP, another hospital for an imaging appointment. Staff told seen within a few days at the hospital and did not have us that the patients would be sympathetically informed to wait for their appointment on arrival to the hospital. at the time of their consultation. • Patients would be contacted if they did not attend (DNA) • It was not clear how the outpatient and imaging for their appointment. If the patient no longer needed department planned and took account of people with an appointment, a note was put on the patient’s file and complex needs such as dementia. Staff were unable to the consultant informed. The same process was give us any examples of reasonable adjustments to followed for NHS patients. If the patient still needed an make the environment dementia friendly. Staff told us appointment, a further one would be made. However, if they received dementia training via e-learning. the patient DNA for a second time the hospital • The children’s waiting area was limited and was discharged the patient and recorded its decision on the combined into the main waiting area. We saw a lack of patient’s file. toys and toys that were available were not age • MRI and CT scans were carried out at the local NHS appropriate. For example, colouring pencils were hospital. A referral from BMI The Runnymede hospital available but did not come complete with paper or a would be made by fax and the NHS hospital would

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Outpatients and diagnostic imaging

book to draw or colour with. There were several building • Managers told us that they felt able to ‘challenge’ blocks and a few books only suitable for younger consultants if care practices were compromised and children. Staff told us parents had commented on the would escalate to executive director for staff related lack of space and age appropriate toys for their child. incident. • There were leaflets to encourage patients and their Learning from complaints and concerns carers to give feedback to the hospital about the care • Patients were aware of the complaints process. Patients they had received. told us they were happy with the service; however they • Staff felt supported and valued. knew how to raise a concern or complaint if they had However: one. • The hospital had a complaints policy and all staff were • The hospital governance policy had a review date of 30 aware of it and how to support patients who wanted to June 2016 and was therefore out-of-date. complain. However, staff told us that they would seek to Vision and strategy for this this core service resolve any concerns in the first instance. • The hospital’s complaints log demonstrated that • Staff were aware of the local vision and strategy for BMI between October 2015 and June 2016, all complaints Runnymede. Staff told us that part of the local vision were acknowledged within two working days as was to be the private hospital of choice for patients and outlined in the complaints policy. The hospital informed consultants in west Surrey, to deliver high quality us that 95% were responded within twenty working service, be the employer of choice and to continually days as outlined in the policy. improve and update their facilities and environment. • The hospital identified a theme of finance complaints Governance, risk management and quality where patients did not know what the final bill was. The measurement for this core service hospital confirmed that they are working to change their practice to improve the experience for patients. We saw • We reviewed the hospital risk register and noted one risk from the hospital complaints log of a patient being related to the lack of a clinical hand wash sink in the billed incorrectly for physiotherapy treatment. The physiotherapy clinic room. The risk register detailed hospital rectified this by sending the patient the correct actions to mitigate the risks such as a new sink was bill with a written apology. We saw this discussed in the fitted to the room. staff meeting notes. • Staff told us examples of risks in outpatient and imaging departments such as lessons were not always learned Are outpatient and diagnostic imaging and ageing equipment in the imaging department, which we saw on the hospital risk register. However, we services well-led? saw examples of lessons learned being disseminated in staff meeting notes. The notes also demonstrated that Good ––– information was disseminated about learning from incidents and infection control. This meant actions were We found the outpatient and diagnostic imaging services taken and there were sufficient governance systems in good for well-led because: place to assess, monitor and mitigate risks. • The hospital maintained a MAC whose responsibilities • There was a BMI corporate vision and there was included ensuring any new consultant was only granted awareness of the local vision and strategy amongst practising privileges if deemed competent and safe to outpatient and imaging staff. practice. Minutes from the March 2016 meeting • Staff told us they felt supported by their managers and demonstrated various topics were discussed. These managers told us they were proud of their team and the were not limited and included clinical incidents and teamwork. root cause analysis, complaints and patient satisfaction, NICE guidance, clinical audits and clinical policies. • There was a framework and governance structure. Meetings were held regularly for heads of departments

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Outpatients and diagnostic imaging

and clinical governance committee. The information • Nursing staff felt supported by their managers. Staff told from these meetings was shared either through email or us they enjoyed interaction with patients, colleagues via a daily team brief. Staff meetings took place monthly were friendly and there was good teamwork. Managers and sharing of information and learning was seen in the told us they were proud of their staff within their April 2016 staff meeting notes. departments. • The hospital clinical governance policy had a review • Staff were encouraged by the executive team to raise date of 30 June 2016, which was out of date. concerns. The executive team operated an ‘open door’ policy. The executive team acknowledged that Leadership / culture of service discussing concerns about the workplace could be a • There was a clear reporting structure with the executive stressful experience for an individual member of staff director leading the hospital. The director of clinical and told us there was free access to counselling services and an operational services manager reported sessions for all staff; staff could access these without to the executive director. Both clinical and non-clinical referral and they were confidential. departmental leads reported to the director of clinical • Staff were able to challenge consultants when patient services and operational services manager respectively. care was compromised. Where staff were unable to Within the structure, there were named leads such as a challenge some consultants in other situations, they MAC chair, two leads for infection prevention and escalated the incident with the management team. For control, children’s services and safeguarding. example, a staff member who witnessed a consultant • MAC meetings were held regularly every quarter. These raise his voice in front of patients at another staff were very well documented, with an enormous amount member who carried on with duty without reporting the of information circulated in advance. Minutes incident, reported it to the management team. demonstrated robust discussions and appropriate Public and staff engagement challenges. An example from the March 2016 meeting minutes demonstrated the suspension and withdrawal • Patient experience surveys were available in the of practising privileges for issues such as safeguarding, outpatient department. The hospital received high misconduct allegations and incorrect paperwork, and satisfaction rates. We saw 98% of 410 responses rated practising privileges were revoked for some consultants good or excellent in June 2016. who did not provide the required paperwork. • There were leaflets in waiting areas encouraging patients and their carers to provide feedback about the • Managers were proud of their staff and provided an care they received. We saw staff encouraged patients to example where staff had opportunities to progress fill in feedback forms. within the department such as being promoted for taking on additional responsibility. Innovation, improvement and sustainability • Staff felt valued and said the managers in the hospital • Staff in the diagnostic imaging and physiotherapy were approachable. departments shared learning across the BMI network to • Staff were aware of who the executive team were and encourage improvement. told us that the executive leaders frequently visited the departments during the working day. Staff told us that the senior management team had an ‘open door’ policy and were approachable.

65 BMI The Runnymede Hospital Quality Report 25/01/2017 Outst anding pr actic e and ar as f or impr ovement

Outstanding practice and areas for improvement

Areas for improvement

Action the hospital SHOULD take to improve • Ensure that the governance policy is up-to-date. Action the hospital SHOULD take to improve • Consider improving the environment for children in • Ensure that the flooring in all clinical areas is fit for the outpatients department so that it is child-friendly. purpose. • Consider providing written information to service • Ensure clinical staff who assess children are trained in users for whom English is not their first language safeguarding children level three.

66 BMI The Runnymede Hospital Quality Report 25/01/2017